DHS 107.16(2)(g) (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.
DHS 107.16(2)(h) (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 Note: For more information on prior authorization, see s. DHS 107.02 (3).
DHS 107.16(3) (3)Other limitations.
DHS 107.16(3)(a) (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:
DHS 107.16(3)(a)1. 1. 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
DHS 107.16(3)(a)2. 2. 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.
DHS 107.16(3)(b) (b) Restorative therapy services. Restorative therapy services shall be covered services, except as provided in sub. (4) (b).
DHS 107.16(3)(c) (c) Maintenance therapy services. Preventive or maintenance therapy services shall be covered services only when one of the following conditions are met:
DHS 107.16(3)(c)1. 1. The skills and training of a therapist are required to execute the entire preventive and maintenance program;
DHS 107.16(3)(c)2. 2. 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
DHS 107.16(3)(c)3. 3. When, due to the severity or complexity of the recipient's condition, nursing personnel cannot handle the recipient safely and effectively.
DHS 107.16(3)(d) (d) Evaluations. 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.
DHS 107.16(3)(e) (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:
DHS 107.16(3)(e)1. 1. 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;
DHS 107.16(3)(e)2. 2. 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;
DHS 107.16(3)(e)3. 3. The recipient has achieved independence in daily activities or can be supervised and assisted by restorative nursing personnel;
DHS 107.16(3)(e)4. 4. The evaluation indicates that the recipient's abilities are functional for the person's present way of life;
DHS 107.16(3)(e)5. 5. The recipient shows no motivation, interest, or desire to participate in therapy, which may be for reasons of an overriding severe emotional disturbance;
DHS 107.16(3)(e)6. 6. Other therapies are providing sufficient services to meet the recipient's functioning needs; or
DHS 107.16(3)(e)7. 7. 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.
DHS 107.16(4) (4)Non-covered services. The following services are not covered services:
DHS 107.16(4)(a) (a) 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;
DHS 107.16(4)(b) (b) Those services that can be performed by restorative nursing, as under s. DHS 132.60 (1) (b) through (d);
DHS 107.16(4)(c) (c) 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;
DHS 107.16(4)(d) (d) Group physical therapy services; and
DHS 107.16(4)(e) (e) 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 Note: For more information on non-covered services, see s. DHS 107.03.
DHS 107.16 History 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.
DHS 107.17 DHS 107.17Occupational therapy.
DHS 107.17(1)(1)Covered services. 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):
DHS 107.17(1)(a) (a) Motor skills, as follows:
DHS 107.17(1)(a)1. 1. Range-of-motion;
DHS 107.17(1)(a)2. 2. Gross/fine coordination;
DHS 107.17(1)(a)3. 3. Strengthening;
DHS 107.17(1)(a)4. 4. Endurance/tolerance; and
DHS 107.17(1)(a)5. 5. Balance;
DHS 107.17(1)(b) (b) Sensory integrative skills, as follows:
DHS 107.17(1)(b)1. 1. Reflex/sensory status;
DHS 107.17(1)(b)2. 2. Body concept;
DHS 107.17(1)(b)3. 3. Visual-spatial relationships;
DHS 107.17(1)(b)4. 4. Posture and body integration; and
DHS 107.17(1)(b)5. 5. Sensorimotor integration;
DHS 107.17(1)(c) (c) Cognitive skills, as follows:
DHS 107.17(1)(c)1. 1. Orientation;
DHS 107.17(1)(c)2. 2. Attention span;
DHS 107.17(1)(c)3. 3. Problem-solving;
DHS 107.17(1)(c)4. 4. Conceptualization; and
DHS 107.17(1)(c)5. 5. Integration of learning;
DHS 107.17(1)(d) (d) Activities of daily living skills, as follows:
DHS 107.17(1)(d)1. 1. Self-care;
DHS 107.17(1)(d)2. 2. Work skills; and
DHS 107.17(1)(d)3. 3. Avocational skills;
DHS 107.17(1)(e) (e) Social interpersonal skills, as follows:
DHS 107.17(1)(e)1. 1. Dyadic interaction skills; and
DHS 107.17(1)(e)2. 2. Group interaction skills;
DHS 107.17(1)(f) (f) Psychological intrapersonal skills, as follows:
DHS 107.17(1)(f)1. 1. Self-identity and self-concept;
DHS 107.17(1)(f)2. 2. Coping skills; and
DHS 107.17(1)(f)3. 3. Independent living skills;
DHS 107.17(1)(g) (g) Preventive skills, as follows:
DHS 107.17(1)(g)1. 1. Energy conservation;
DHS 107.17(1)(g)2. 2. Joint protection;
DHS 107.17(1)(g)3. 3. Edema control; and
DHS 107.17(1)(g)4. 4. Positioning;
DHS 107.17(1)(h) (h) Therapeutic adaptions, as follows:
DHS 107.17(1)(h)1. 1. Orthotics/splinting;
DHS 107.17(1)(h)2. 2. Prosthetics;
DHS 107.17(1)(h)3. 3. Assistive/adaptive equipment; and
DHS 107.17(1)(h)4. 4. Environmental adaptations;
DHS 107.17(1)(i) (i) Environmental planning; and
DHS 107.17(1)(j) (j) 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:
DHS 107.17(1)(j)1. 1. Motor skills:
DHS 107.17(1)(j)1.a. a. Range-of-motion;
DHS 107.17(1)(j)1.b. b. Gross muscle test;
DHS 107.17(1)(j)1.c. c. Manual muscle test;
DHS 107.17(1)(j)1.d. d. Coordination evaluation;
DHS 107.17(1)(j)1.e. e. Nine hole peg test;
DHS 107.17(1)(j)1.f. f. Purdue pegboard test;
DHS 107.17(1)(j)1.g. g. Strength evaluation;
DHS 107.17(1)(j)1.h. h. Head-trunk balance evaluation;
DHS 107.17(1)(j)1.i. i. Standing balance — endurance;
DHS 107.17(1)(j)1.j. j. Sitting balance — endurance;
DHS 107.17(1)(j)1.k. k. Prosthetic check-out;
DHS 107.17(1)(j)1.L. L. Hemiplegic evaluation;
DHS 107.17(1)(j)1.m. m. Arthritis evaluation; and
DHS 107.17(1)(j)1.n. n. Hand evaluation — strength and range-of-motion;
DHS 107.17(1)(j)2. 2. Sensory integrative skills:
DHS 107.17(1)(j)2.a. a. Beery test of visual motor integration;
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.