(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)
Evaluations or re-evaluations. Covered evaluations, the results of which shall be set out in a written report attached to the test chart or form in the recipient's medical record, are the following: