Functional training, also known as activities of daily living — self-care training, transfers and wheelchair independence;
Services which are reimbursable when performed by a physical therapy aide meeting the requirements of subds. 2.
are the following:
Performing simple activities required to prepare a recipient for treatment, assist in the performance of treatment, or assist at the conclusion of treatment, such as assisting the recipient to dress or undress, transferring a recipient to or from a mat, and applying or removing orthopedic devices;
DHS 107.16 Note
Note: Transportation of the recipient to or from the area in which therapy services are provided is not reimbursable.
Assembling and disassembling equipment and accessories in preparation for treatment or after treatment has taken place;
DHS 107.16 Note
Note: Examples of activities are adjustment of restorator, N.K. table, cybex, weights and weight boots for the patient, and the filling, cleaning and emptying of whirlpools.
Assisting with the use of equipment and performing simple modalities once the recipient's program has been established and the recipient's response to the equipment or modality is highly predictable; and
DHS 107.16 Note
Note: Examples of activities are application of hot or cold packs, application of paraffin, assisting recipient with whirlpool, tilt table, weights and pulleys.
Providing protective assistance during exercise, activities of daily living, and ambulation activities related to the development of strength and refinement of activity.
DHS 107.16 Note
Note: Examples of activities are improving recipient's gait safety and functional distance technique through repetitious gait training and increasing recipient's strength through the use of such techniques as weights, pulleys, and cane exercises.
The physical therapy aide shall be trained in a manner appropriate to his or her job duties. The supervising therapist is responsible for the training of the aide or for securing documentation that the aide has been trained by a physical therapist. The supervising therapist is responsible for determining and monitoring the aide's competency to perform assigned duties. The supervising therapist shall document in writing the modalities or activities for which the aide has received training.
The physical therapy aide shall provide services under the direct, immediate, one-to-one supervision of a physical therapist. In this subdivision, “direct immediate, one-to-one supervision" means one-to-one supervision with face-to-face contact between the physical therapy aide and the supervising therapist during each treatment session, with the physical therapy aide assisting the therapist by providing services under subd. 1.
The direct immediate one-to-one supervision requirement does not apply to non-billable physical therapy aide services.
The department may exempt a facility providing physical therapy services from the supervision requirement under subd. 3. a.
if it determines that direct, immediate one-to-one supervision is not required for specific assignments which physical therapy aides are performing at that facility. If an exemption is granted, the department shall indicate specific physical therapy aide services for which the exemption is granted and shall set a supervision ratio appropriate for those services.
DHS 107.16 Note
Note: For example, facilities providing significant amounts of hydrotherapy may be eligible for an exemption to the direct, immediate one-to-one supervision requirement for physical therapy aides who fill or clean tubs.
Physical therapy aides may not bill or be reimbursed directly for their services.
DHS 107.16(2)(a)(a) Definition.
In this subsection, “spell of illness" means a condition characterized by a demonstrated loss of functional ability to perform daily living skills, caused by a new disease, injury or medical condition or by an increase in the severity of a pre-existing medical condition. For a condition to be classified as a new spell of illness, the recipient must display the potential to reachieve the skill level that he or she had previously.
Prior authorization is required under this subsection for physical therapy services provided to an MA recipient in excess of 35 treatment days per spell of illness, except that physical therapy services provided to an MA recipient who is a hospital inpatient or who is receiving physical therapy services provided by a home health agency are not subject to prior authorization under this subsection.
DHS 107.16 Note
Physical therapy services provided by a home health agency are subject to prior authorization under s. DHS 107.11 (3)
(c) Conditions justifying spell of illness designation.
The following conditions may justify designation of a new spell of illness:
Neuromuscular dysfunction, including stroke-hemiparesis, multiple sclerosis, Parkinson's disease and diabetic neuropathy;
Musculoskeletal dysfunction, including fracture, amputation, strains and sprains, and complications associated with surgical procedures; or
Problems and complications associated with physiologic dysfunction, including severe pain, vascular conditions, and cardio-pulmonary conditions.
An exacerbation of a pre-existing condition, including but not limited to the following, which requires physical therapy intervention on an intensive basis:
A regression in the recipient's condition due to lack of physical therapy, as indicated by a decrease of functional ability, strength, mobility or motion.
(d) Onset and termination of spell of illness.
The spell of illness begins with the first day of treatment or evaluation following the onset of the new disease, injury or medical condition or increased severity of a pre-existing medical condition and ends when the recipient improves so that treatment by a physical therapist for the condition causing the spell of illness is no longer required, or after 35 treatment days, whichever comes first.
The physical therapist shall document the spell of illness in the patient plan of care, including measurable evidence that the recipient has incurred a demonstrated functional loss of ability to perform daily living skills.
(f) Non-transferability of treatment days.
Unused treatment days from one spell of illness may not be carried over into a new spell of illness.
(g) Other coverage.
Treatment days covered by medicare or other third-party insurance shall be included in computing the 35-day per spell of illness total.
(h) Department expertise.
The department may have on its staff qualified physical therapists to develop prior authorization criteria and perform other consultative activities.
DHS 107.16 Note
For more information on prior authorization, see s. DHS 107.02 (3)
(a) Plan of care for therapy services.
Services shall be furnished to a recipient under a plan of care established and periodically reviewed by a physician. The plan shall be reduced to writing before treatment is begun, either by the physician who makes the plan available to the provider or by the provider of therapy when the provider makes a written record of the physician's oral orders. The plan shall be promptly signed by the ordering physician and incorporated into the provider's permanent record for the recipient. The plan shall:
State the type, amount, frequency and duration of the therapy services that are to be furnished the recipient and shall indicate the diagnosis and anticipated goals. Any changes shall be made in writing and signed by the physician, the provider of therapy services or the physician on the staff of the provider pursuant to the attending physician's oral orders; and
Be reviewed by the attending physician in consultation with the therapist providing services, at whatever intervals the severity of the recipient's condition requires, but at least every 90 days. Each review of the plan shall be indicated on the plan by the initials of the physician and the date performed. The plan for the recipient shall be retained in the provider's file.
(b) Restorative therapy services.
Restorative therapy services shall be covered services, except as provided in sub. (4) (b)
(c) Maintenance therapy services.
Preventive or maintenance therapy services shall be covered services only when one of the following conditions are met:
The skills and training of a therapist are required to execute the entire preventive and maintenance program;
The specialized knowledge and judgment of a physical therapist are required to establish and monitor the therapy program, including the initial evaluation, the design of the program appropriate to the individual recipient, the instruction of nursing personnel, family or recipient, and the necessary re-evaluations; or
When, due to the severity or complexity of the recipient's condition, nursing personnel cannot handle the recipient safely and effectively.
Evaluations shall be covered services. The need for an evaluation or re-evaluation shall be documented in the plan of care. Evaluations shall be counted toward the 35-day per spell of illness prior authorization threshold.
(e) Extension of therapy services.
Extension of therapy services shall not be approved beyond the 35-day per spell of illness prior authorization threshold in any of the following circumstances:
The recipient has shown no progress toward meeting or maintaining established and measurable treatment goals over a 6-month period, or the recipient has shown no ability within 6 months to carry over abilities gained from treatment in a facility to the recipient's home;
The recipient's chronological or developmental age, way of life or home situation indicates that the stated therapy goals are not appropriate for the recipient or serve no functional or maintenance purpose;
The recipient has achieved independence in daily activities or can be supervised and assisted by restorative nursing personnel;
The evaluation indicates that the recipient's abilities are functional for the person's present way of life;
The recipient shows no motivation, interest, or desire to participate in therapy, which may be for reasons of an overriding severe emotional disturbance;
Other therapies are providing sufficient services to meet the recipient's functioning needs; or
The procedures requested are not medical in nature or are not covered services. Inappropriate diagnoses for therapy services and procedures of questionable medical necessity may not receive departmental authorization, depending upon the individual circumstances.
(4) Non-covered services.
The following services are not covered services:
Services related to activities for the general good and welfare of recipients, such as general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation;
Activities such as end-of-the-day clean-up time, transportation time, consultations and required paper reports. These are considered components of the provider's overhead costs and are not covered as separately reimbursable items;
When performed by a physical therapy aide, interpretation of physician referrals, patient evaluation, evaluation of procedures, initiation or adjustment of treatment, assumption of responsibility for planning patient care, or making entries in patient records.
DHS 107.16 Note
For more information on non-covered services, see s. DHS 107.03
DHS 107.16 History
Cr. Register, February, 1986, No 362
, eff. 3-1-86; emerg. am. (2) (b), (d), (g), (3) (d) and (e) (intro.), eff. 7-1-88; am. (2) (b), (d), (g), (3) (d) and (e) (intro.), Register, December, 1988, No. 396
, eff. 1-1-89; correction in (4) (b) made under s. 13.92 (4) (b) 7.
, Stats., Register December 2008 No. 636
Covered occupational therapy services are the following medically necessary services when prescribed by a physician and performed by a certified occupational therapist (OT) or by a certified occupational therapist assistant (COTA) under the direct, immediate, on-premises supervision of a certified occupational therapist or, for services under par. (d)
, by a certified occupational therapist assistant under the general supervision of a certified occupational therapist pursuant to the requirements of s. DHS 105.28 (2)