DHS 107.17(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.
DHS 107.17(2)(b)
(b) Requirement. Prior authorization is required under this subsection for occupational therapy services provided to an MA recipient in excess of 35 treatment days per spell of illness, except that occupational therapy services provided to an MA recipient who is a hospital inpatient or who is receiving occupational therapy services provided by a home health agency are not subject to prior authorization under this subsection.
DHS 107.17 Note
Note: Occupational therapy services provided by a home health agency are subject to prior authorization under s.
DHS 107.11 (3).
DHS 107.17(2)(c)
(c) Conditions justifying spell of illness designation. The following conditions may justify designation of a new spell of illness:
DHS 107.17(2)(c)1.a.
a. Neuromuscular dysfunction, including stroke-hemiparesis, multiple sclerosis, Parkinson's disease and diabetic neuropathy;
DHS 107.17(2)(c)1.b.
b. Musculoskeletal dysfunction, including fracture, amputation, strains and sprains, and complications associated with surgical procedures;
DHS 107.17(2)(c)1.c.
c. Problems and complications associated with physiologic dysfunction, including severe pain, vascular conditions, and cardio-pulmonary conditions; or
DHS 107.17(2)(c)1.d.
d. Psychological dysfunction, including thought disorders, organic conditions and affective disorders;
DHS 107.17(2)(c)2.
2. An exacerbation of a pre-existing condition including but not limited to the following, which requires occupational therapy intervention on an intensive basis:
DHS 107.17(2)(c)3.
3. A regression in the recipient's condition due to lack of occupational therapy, as indicated by a decrease of functional ability, strength, mobility or motion.
DHS 107.17(2)(d)
(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 an occupational therapist for the condition causing the spell of illness is no longer required, or after 35 treatment days, whichever comes first.
DHS 107.17(2)(e)
(e) Documentation. The occupational 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.
DHS 107.17(2)(f)
(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.
DHS 107.17(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 107.17(2)(h)
(h) Department expertise. The department may have on its staff qualified occupational therapists to develop prior authorization criteria and perform other consultative activities.
DHS 107.17 Note
Note: For more information about prior authorization, see s.
DHS 107.02 (3).
DHS 107.17(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 107.17(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 107.17(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 107.17(3)(b)
(b) Restorative therapy services. Restorative therapy services shall be covered services except as provided under sub.
(4) (b).
DHS 107.17(3)(c)
(c) 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 107.17(3)(d)
(d) Maintenance therapy services. Preventive or maintenance therapy services shall be covered services only when one or more of the following conditions are met:
DHS 107.17(3)(d)1.
1. The skills and training of a therapist are required to execute the entire preventive and maintenance program;
DHS 107.17(3)(d)2.
2. The specialized knowledge and judgment of an occupational 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 re-evaluations required; or
DHS 107.17(3)(d)3.
3. When, due to the severity or complexity of the recipient's condition, nursing personnel cannot handle the recipient safely and effectively.
DHS 107.17(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 107.17(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 107.17(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 107.17(3)(e)3.
3. The recipient has achieved independence in daily activities or can be supervised and assisted by restorative nursing personnel;
DHS 107.17(3)(e)4.
4. The evaluation indicates that the recipient's abilities are functional for the person's present way of life;
DHS 107.17(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 107.17(3)(e)6.
6. Other therapies are providing sufficient services to meet the recipient's functioning needs; or
DHS 107.17(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 107.17(4)
(4)
Non-covered services. The following services are not covered services:
DHS 107.17(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 107.17(4)(c)
(c) Crafts and other supplies used in occupational therapy services for inpatients in an institutional program. These are not billable by the therapist; and
DHS 107.17(4)(d)
(d) 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 107.17 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.17 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; emerg. am. (2) (b), (d), (g), (3) (c) and (e) (intro.), eff. 7-1-88; am. (2) (b) (d), (g) (3) (c) and (e) (intro.),
Register, December, 1988, No. 396, eff. 1-1-89; corrections in (1) (intro.) and (4) (b) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
