DWD 81.09(2)(b)
(b) A health care provider shall at each visit reassess the appropriateness of the clinical category assigned and reassign the patient if warranted by new clinical information including symptoms, signs, results of diagnostic testing and opinions, and information obtained from consultations with other health care providers. When the clinical category is changed the treatment plan shall be appropriately modified to reflect the new clinical category. The health care provider shall record any clinical category and treatment plan changes in the medical record. A change of clinical category may not in itself allow a health care provider to continue a therapy or treatment modality past the maximum duration specified in
subs. (3) to
(10) or to repeat a therapy or treatment previously provided for the same injury, unless the treatment or therapy is subsequently delivered to a different part of the body.
DWD 81.09(2)(c)
(c) When treating more than one clinical category or body part for which the same treatment modality is appropriate, then the treatment modality shall be applied simultaneously, if possible, to all necessary areas.
DWD 81.09(2)(d)
(d) In general, a course of treatment shall be divided into the following 3 phases:
DWD 81.09(2)(d)1.
1. First, all patients with an upper extremity disorder shall be given initial nonsurgical management, unless otherwise specified. Initial nonsurgical management may include any combination of the passive, active, injection, durable medical equipment, and medication treatment modalities listed in
subs. (3),
(4),
(5),
(8), and
(10), appropriate to the clinical category. The period of initial nonsurgical treatment begins with the first passive, active, injection, durable medical equipment, or medication modality initiated. Initial nonsurgical treatment shall result in progressive improvement as specified in
sub. (9).
DWD 81.09(2)(d)2.
2. Second, for patients with persistent symptoms, initial nonsurgical management is followed by a period of surgical evaluation. This evaluation shall be completed in a timely manner. Surgery, if necessary, shall be performed as expeditiously as possible consistent with sound medical practice and
subs. (6),
(11) to
(16), and
s. DWD 81.12 (2). A treating health care provider may do the evaluation or may refer the patient to another health care provider.
DWD 81.09(2)(d)2.a.
a. Any patient who has had surgery may require postoperative therapy with active and passive treatment modalities. This therapy may be in addition to any received during the period of initial nonsurgical management.
DWD 81.09(2)(d)2.c.
c. A decision against surgery at any particular time does not preclude a decision for surgery made at a later date.
DWD 81.09(2)(d)3.
3. Third, for those patients who are not candidates for surgery or refuse surgery, or who do not have complete resolution of their symptoms with surgery, a period of chronic management may be necessary. Chronic management modalities are described in
s. DWD 81.13 and may include durable medical equipment as described in
sub. (8).
DWD 81.09(2)(e)
(e) A treating health care provider may refer the patient for a consultation at any time during the course of treatment consistent with accepted medical practice.
DWD 81.09(3)(a)(a)
General. Except as set forth in
par. (b) or
s. DWD 81.04 (5), a health care provider may not direct the use of passive treatment modalities in a clinical setting as set forth in
pars. (c) to
(i) beyond 12 calendar weeks after any of the passive modalities in
pars. (c) to
(i) are initiated. There are no limitations on the use of passive treatment modalities by the patient at home.
DWD 81.09(3)(b)
(b)
Additional passive treatment modalities. A health care provider may direct an additional 12 visits for the use of passive treatment modalities over an additional 12 months if all of the following apply:
DWD 81.09(3)(b)1.
1. The patient is released to work or is permanently totally disabled and the additional passive treatment may result in progressive improvement in, or maintenance of, functional status achieved during the initial 12 weeks of passive care.
DWD 81.09(3)(b)3.
3. A health care provider documents in the medical record a plan to encourage the patient's independence and decreased reliance on health care providers.
DWD 81.09(3)(b)4.
4. Management of the patient's condition includes active treatment modalities during this period.
DWD 81.09(3)(b)5.
5. The additional 12 visits for passive treatment does not delay the required surgical or chronic pain evaluation required by this chapter.
DWD 81.09(3)(b)6.
6. Passive care is not necessary while the patient has chronic pain syndrome.
DWD 81.09(3)(c)
(c)
Adjustment or manipulation of joints. For purposes of this paragraph, “adjustment or manipulation of joints" includes chiropractic and osteopathic adjustments or manipulations. All of the following guidelines apply to adjustment or manipulation of joints:
DWD 81.09(3)(c)2.
2. Maximum treatment frequency is up to 5 times per week for the first one to 2 weeks decreasing in frequency until the end of the maximum treatment duration period in
subd. 3.
DWD 81.09(3)(d)
(d)
Thermal treatment. For purposes of this paragraph, “thermal treatment" includes all superficial and deep heating and cooling modalities. Superficial thermal modalities include hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soaks, infrared, whirlpool, and fluidotherapy. Deep thermal modalities include diathermy, ultrasound, and microwave. All of the following guidelines apply to thermal treatment:
DWD 81.09(3)(d)1.b.
b. Maximum treatment frequency is up to 5 times per week for the first one to 3 weeks, decreasing in frequency until the end of the maximum treatment duration period in
subd. 1. c.
DWD 81.09(3)(d)1.c.
c. Maximum treatment duration is 12 weeks of treatment in a clinical setting but only if given in conjunction with other therapies.
DWD 81.09(3)(d)2.
2. Home use of thermal modalities may be prescribed at any time during the course of treatment. Home use may only involve hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, and cold soaks that can be applied by the patient without health care provider assistance. Home use of thermal modalities may not require any special training or monitoring, other than that usually provided by a health care provider during an office visit.
DWD 81.09(3)(e)
(e)
Electrical muscle stimulation. For purposes of this paragraph, “electrical muscle stimulation" includes galvanic stimulation, transcutaneous electrical nerve stimulation, interferential and microcurrent techniques. All of the following guidelines apply to electrical muscle stimulation:
DWD 81.09(3)(e)1.b.
b. Maximum treatment frequency is up to 5 times per week for the first one to 3 weeks, decreasing in frequency until the end of the maximum treatment duration period in
subd. 1. c.
DWD 81.09(3)(e)1.c.
c. Maximum treatment duration is 12 weeks of treatment in a clinical setting but only if given in conjunction with other therapies.
DWD 81.09(3)(e)2.
2. Home use of an electrical muscle stimulation device may be prescribed at any time during a course of treatment. Initial use of an electrical stimulation device shall be in a supervised setting in order to ensure proper electrode placement and patient education. All of the following guidelines apply to home use of an electrical stimulation device:
DWD 81.09(3)(e)2.b.
b. Patient may use the electrical stimulation device unsupervised for one month, at which time effectiveness of the treatment shall be reevaluated by a health care provider before continuing home use of the device.
DWD 81.09(3)(f)
(f)
Acupuncture treatments. For purposes of this paragraph, “acupuncture treatments" include endorphin-mediated analgesic therapy that includes classic acupuncture and acupressure. All of the following guidelines apply to acupuncture treatments:
DWD 81.09(3)(f)2.
2. Maximum treatment frequency is up to 3 times per week for the first one to 3 weeks, decreasing in frequency until the end of the maximum treatment duration period in
subd. 3.
DWD 81.09(3)(g)
(g)
Phoresis. For purposes of this paragraph, “phoresis" includes phonopheresis and iontophoresis. All of the following guidelines apply to phoresis:
DWD 81.09(3)(g)2.
2. Maximum treatment frequency is up to 3 times per week for the first one to 3 weeks, decreasing in frequency until the end of the maximum treatment duration period in
subd. 3.
DWD 81.09(3)(g)3.
3. Maximum treatment duration is 9 sessions of either iontophoresis or phonophoresis, or combination, to any one site, with a maximum duration of 12 weeks for all treatment.
DWD 81.09(3)(h)
(h)
Manual therapy. For purposes of this paragraph, “manual therapy" includes soft tissue and joint mobilization and therapeutic massage. All of the following guidelines apply to manual therapy:
DWD 81.09(3)(h)2.
2. Maximum treatment frequency is up to 5 times per week for the first one to 2 weeks decreasing in frequency until the end of the maximum treatment duration period in
subd. 3.
DWD 81.09(3)(i)
(i)
Splints, braces, and other movement-restricting appliances. Bracing required for longer than 2 weeks shall be accompanied by active motion exercises to avoid stiffness and prolonged disability. All of the following guidelines apply to splints, braces, and other movement-restricting appliances:
DWD 81.09(3)(i)2.
2. Maximum treatment frequency is limited to intermittent use during times of increased physical stress or prophylactic use at work.
DWD 81.09(3)(i)3.
3. Maximum continuous duration is 8 weeks. Prophylactic use is allowed indefinitely.
DWD 81.09(3)(j)
(j)
Rest. Prolonged restriction of activity and immobilization are detrimental to a patient's recovery. Total restriction of use of an affected body part may not be prescribed for more than 2 weeks, unless rigid immobilization is required. In cases of rigid immobilization, active motion exercises at adjacent joints shall begin no later than 2 weeks after application of the immobilization.
DWD 81.09(4)(a)(a) A health care provider shall use active treatment modalities as set forth in
pars. (b) to
(f). A health care provider's use of active treatment modalities may extend past the 12-week limitation on passive treatment modalities so long as the maximum treatment for the active treatment modality is not exceeded.
DWD 81.09(4)(b)
(b) Education shall teach the patient about pertinent anatomy and physiology as it relates to upper extremity function for the purpose of injury prevention. Education includes training on posture, biomechanics, and relaxation. The maximum number of treatments is 3 visits which include an initial education and training session, and 2 follow-up visits.
DWD 81.09(4)(c)
(c) Posture and work method training shall instruct the patient in the proper performance of job activities. Topics include proper positioning of the trunk, neck, and arms, use of optimum biomechanics in performing job tasks, and appropriate pacing of activities. Methods include didactic sessions, demonstrations, exercises, and simulated work tasks. The maximum number of treatments is 3 visits.
DWD 81.09(4)(d)
(d) Worksite analysis and modification shall examine the patient's work station, tools, and job duties. A health care provider may make recommendations for the alteration of the work station, selection of alternate tools, modification of job duties, and provision of adaptive equipment. The maximum number of treatments is 3 visits.
DWD 81.09(4)(e)
(e) Exercise, which is important to the success of a nonsurgical treatment program and a return to normal activity, shall include active patient participation in activities designed to increase flexibility, strength, endurance, or muscle relaxation. Exercise shall, at least in part, be specifically aimed at the musculature of the upper extremity. While aerobic exercise may be performed as adjunctive treatment, this shall not be the primary focus of the exercise program.
DWD 81.09(4)(f)
(f) Exercises shall be evaluated to determine if the desired goals are being attained. Strength, flexibility, or endurance shall be objectively measured. A health care provider may objectively measure the treatment response as often as necessary for optimal care after the initial evaluation.
Subdivisions 1. and
2. govern supervised and unsupervised exercise, except for computerized exercise programs and health clubs, which are governed by
s. DWD 81.13.
DWD 81.09(4)(f)1.
1. `Guidelines for supervised exercise.' One goal of an exercise program shall be to teach the patient how to maintain and maximize any gains experienced from exercise. Self-management of the condition shall be promoted. All of the following guidelines apply to supervised exercise:
DWD 81.09(4)(f)1.a.
a. Maximum treatment frequency is up to 3 times per week for 3 weeks and shall decrease with time until the end of the maximum treatment duration period in
subd. 1. b.
DWD 81.09(4)(f)2.
2. `Guidelines for unsupervised exercise.' Unsupervised exercise shall be provided in the least intensive setting and may supplement or follow the period of supervised exercise.
DWD 81.09(5)(a)(a) For purposes of this subsection, “therapeutic injections" include injections of trigger points, sympathetic nerves, peripheral nerves, and soft tissues. A health care provider may only give therapeutic injections in conjunction with active treatment modalities directed to the same anatomical site. A health care provider's use of injections may extend past the 12-week limitation on passive modalities, so long as the maximum treatment for injections in
pars. (b) to
(d) is not exceeded.
DWD 81.09(5)(b)
(b) All of the following guidelines apply to trigger point injections:
DWD 81.09(5)(b)2.
2. Maximum treatment frequency is once per week to any one site if there is a positive response to the first injection at that site. If subsequent injections at that site demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, trigger point injections shall be redirected to other areas or discontinued. Only 3 injections to different sites per patient visit.
DWD 81.09(5)(b)3.
3. Maximum treatment is 4 injections to any one site over the course of treatment.
DWD 81.09(5)(c)
(c) For purposes of this paragraph, “soft tissue injections" include injections of a bursa, tendon, tendon sheath, ganglion, tendon insertion, ligament, or ligament insertion. All of the following guidelines apply to soft tissue injections:
DWD 81.09(5)(c)2.
2. Maximum treatment frequency is once per month to any one site if there is a positive response to the first injection. If subsequent injections demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then injections shall be discontinued. Only 3 injections to different sites per patient visit.
DWD 81.09(5)(c)3.
3. Maximum treatment is 3 injections to any one site over the course of treatment.
DWD 81.09(5)(d)
(d) All of the following guidelines apply to injections for median nerve entrapment at the carpal tunnel:
DWD 81.09(5)(d)2.
2. Maximum treatment frequency may permit repeat injection in one month if there is a positive response to the first injection. Only 3 injections to different sites per patient visit.
DWD 81.09(5)(d)3.
3. Maximum treatment is 2 injections to any one site over the course of treatment.
DWD 81.09(6)(b)
(b) In order to optimize the beneficial effect of surgery, postoperative therapy with active and passive treatment modalities may be provided, even if these modalities had been used in the preoperative treatment of the condition. In the postoperative period the maximum treatment duration with passive treatment modalities in a clinical setting from initiation of the first passive modality used, except bedrest or bracing, is as follows:
DWD 81.09(6)(b)1.
1. Sixteen weeks for rotator cuff repair, acromioclavicular ligament repair, or any surgery for a clinical category in this section that requires joint reconstruction.
DWD 81.09(6)(b)2.
2. Eight weeks for all other surgery for clinical categories in this section.
DWD 81.09(7)
(7) Chronic management. Chronic management of upper extremity disorders shall be provided according to the guidelines in
s. DWD 81.13.
DWD 81.09(8)(a)(a) A health care provider may direct the use of durable medical equipment only in the situations specified in
pars. (b) to
(e).
