DHS 107.06(4)(a)
(a) Physician's visits. A maximum of one physician's visit per month to a recipient confined to a nursing home is covered unless the recipient has an acute condition which warrants more frequent care, in which case the recipient's medical record shall document the necessity of additional visits. The attending physician of a nursing home recipient, or the physician's assistant, or a nurse practitioner under the supervision of a physician, shall reevaluate the recipient's need for nursing home care in accordance with s.
DHS 107.09 (4) (m).
DHS 107.06(4)(b)
(b) Services of a surgical assistant. The services of a surgical assistant are not covered for procedures which normally do not require assistance at surgery.
DHS 107.06(4)(c)
(c) Consultations. Certain consultations shall be covered if they are professional services furnished to a recipient by a second physician at the request of the attending physician. Consultations shall include a written report which becomes a part of the recipient's permanent medical record. The name of the attending physician shall be included on the consultant's claim for reimbursement. The following consultations are covered:
DHS 107.06(4)(c)1.
1. Consultation requiring limited physical examination and evaluation of a given system or systems;
DHS 107.06(4)(c)2.
2. Consultation requiring a history and direct patient confrontation by a psychiatrist;
DHS 107.06(4)(c)3.
3. Consultation requiring evaluation of frozen sections or pathological slides by a pathologist; and
DHS 107.06(4)(c)4.
4. Consultation involving evaluation of radiological studies or radiotherapy by a radiologist;
DHS 107.06(4)(cm)
(cm)
Interprofessional consultation. Interprofessional consultations shall be covered if all of the following apply:
DHS 107.06(4)(cm)1.
1. The consultation is a professional service furnished to a recipient by a certified provider at the request of the treating provider.
DHS 107.06(4)(cm)2.
2. The consultation constitutes an evaluation and management service in which the certified provider treating a recipient requests the opinion or treatment advice of a consulting provider with specific expertise to assist the treating provider in the evaluation or management of the recipient’s problem without requiring the recipient to have face-to-face contact with the consulting provider.
DHS 107.06(4)(cm)3.
3. The consulting provider provides a written report that becomes a part of the recipient's permanent medical record.
DHS 107.06(4)(d)1.1. Services pertaining to the cleaning, trimming, and cutting of toenails, often referred to as palliative care, maintenance care, or debridement, shall be reimbursed no more than one time for each 31-day period and only if the recipient's condition is one or more of the following:
DHS 107.06(4)(d)1.c.
c. Peripheral neuropathies involving the feet, which are associated with malnutrition or vitamin deficiency, carcinoma, diabetes mellitus, drugs and toxins, multiple sclerosis, uremia or cerebral palsy.
DHS 107.06(4)(d)2.
2. The cutting, cleaning and trimming of toenails, corns, callouses and bunions on multiple digits shall be reimbursed at one inclusive fee for each service which includes either one or both appendages.
DHS 107.06(4)(d)3.
3. For multiple surgical procedures performed on the foot on the same day, the physician shall be reimbursed for the first procedure at the full rate and the second and all subsequent procedures at a reduced rate as determined by the department.
DHS 107.06(4)(d)4.
4. Debridement of mycotic conditions and mycotic nails shall be a covered service in accordance with utilization guidelines established and published by the department.
DHS 107.06(4)(d)5.
5. The application of unna boots is allowed once every 2 weeks, with a maximum of 12 applications for each 12-month period.
DHS 107.06(4)(f)
(f) Services performed under a physician's supervision. Services performed under the supervision of a physician shall comply with federal and state regulations relating to supervision of covered services. Specific documentation of the services shall be included in the recipient's medical record.
DHS 107.06(4)(g)
(g) Dental services. Dental services performed by a physician shall be subject to all requirements for MA dental services described in s.
DHS 107.07.
DHS 107.06(4)(h)
(h) Obesity-related procedures. Gastric bypass or gastric stapling for obesity is limited to medical emergencies, as determined by the department.
DHS 107.06(4)(i)1.1. Abortions, both surgically-induced and drug-induced, are limited to those that comply with s.
20.927, Stats.
DHS 107.06(4)(i)2.
2. Services, including drugs, directly related to non-surgical abortions shall comply with s.
20.927, Stats., may only be prescribed by a physician, and shall comply with MA policy and procedures as described in MA provider handbooks and bulletins.
DHS 107.06(5)
(5) Non-covered services. The following services are not covered services:
DHS 107.06(5)(a)
(a) Services and items that are provided for the purpose of enhancing the prospects of fertility in males or females, within the meaning of s.
DHS 107.03 (19).
DHS 107.06(5)(d)
(d) As separate charges, preoperative and postoperative surgical care, including office visits for suture and cast removal, which commonly are included in the payment of the surgical procedure;
DHS 107.06(5)(e)
(e) As separate charges, transportation expenses incurred by a physician, to include but not limited to mileage;
DHS 107.06(5)(g)
(g) Except as provided in sub.
(3) (b) 1., a hysterectomy if it was performed solely for the purpose of rendering an individual permanently incapable of reproducing or, if there was more than one purpose to the procedure, it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing;
DHS 107.06(5)(m)
(m) Lincocin (lincomycin) injections performed on an outpatient basis;
DHS 107.06(5)(n)
(n) Orthopedic shoes and supportive devices such as arch supports, shoe inlays and pads;
DHS 107.06(5)(o)
(o) Services directed toward the care and correction of “flat feet";
DHS 107.06(5)(p)
(p) Sterilization of a mentally incompetent or institutionalized person, or of a person who is less than 21 years of age;
DHS 107.06(5)(q)
(q) Inpatient laboratory tests not ordered by a physician or other responsible practitioner, except in emergencies;
DHS 107.06(5)(r)
(r) Hospital care following admission on a Friday or Saturday, except for emergencies, accident care or obstetrical cases, unless the hospital can demonstrate to the satisfaction of the department that the hospital provides all of its services 7 days a week;
DHS 107.06(5)(w)
(w) Non-emergency gastric bypass or gastric stapling for obesity; and
DHS 107.06 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.06 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; cr. (2) (cm), (4) (h) and (5) (y), am. (4) (a) 3.
Register, February, 1988, No. 386, eff. 3-1-88; am. (4) (a) 1. c., p. and q., cr. (4) (a) 1. r.,
Register, April, 1988, No. 388, eff. 7-1-88; r. (2) (cm) and (5) (y), r. and recr. (4) (h),
Register, December, 1988, No. 396, eff. 1-1-89; r. (2) (zh), (zk), (zo), (zp) and (4) (a), renum. (2) (zi) to (zw) to be (zh) to (zs) and am. renum. (4) (b) to (h) to be (4) (a) to (g), cr. (2) (zt), r. (4) (a),
Register, September, 1991, No. 429, eff. 10-1-91; r. and recr. (2) (h) and (5) (a), r. (2) (zb), (zc), zl), (zn), (zp), (zq) and (zs), renum. (2) (zd), (ze) to (zk), (zm), (zo), (zr) and (zt) to be(zb), (zc) to (zi), (zj), (zk), (zL) and (zm) and am.(2) (zc) and (zm), am. (5) (w) and (x), cr. (2) (zn) and (zo), (4) (h) and (i),
Register, January, 1997, No. 493, eff. 2-1-97; correction in (4) (a) made under s. 13.93 (2m) (b) 7., Stats.,
Register, April, 1999, No. 520; correction in (3) (b) 3. (intro.) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636; republication of (3) (e) 5. to reinsert text inadvertently dropped in 1991,
Register February 2019 No. 758;
CR 20-039: r. (4) (e)
Register October 2021 No. 790, eff. 11-1-21;
CR 20-068: am. (3) (d) (intro), 1. a. to f., 2. to 6., 7. (intro.), a., b.
Register December 2021 No. 792, eff. 1-1-22;
CR 22-043: am. (1), cr. (4) (cm), r. (5) (c)
Register May 2023 No. 809, eff. 6-1-23;
CR 23-046: r. (3) (b) 1. Register April 2024 No. 820, eff. 5-1-24. DHS 107.065(1)(1)
Covered services. Anesthesiology services covered by the MA program are any medically necessary medical services applied to a recipient to induce the loss of sensation of pain associated with surgery, dental procedures or radiological services. These services are performed by an anesthesiologist certified under s.
DHS 105.05, or by a nurse anesthetist or an anesthesiology assistant certified under s.
DHS 105.055. Anesthesiology services shall include preoperative, intraoperative and postoperative evaluation and management of recipients as appropriate.
DHS 107.065(2)(a)
(a) A nurse anesthetist shall perform services in the presence of a supervising anesthesiologist or performing physician.
DHS 107.065(2)(b)
(b) An anesthesiology assistant shall perform services only in the presence of a supervising anesthesiologist.
DHS 107.065 History
History: Cr.
Register, September, 1991, No. 429, eff. 10-1-91; correction in (1) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 107.07(1)(1)
Covered services; dentists and physicians. Except as provided under subs.
(2),
(3),
(4) and
(4m), all of the following dental services are covered services when provided by or under the supervision of a dentist or physician within the scope of practice of dentistry as defined in s.
447.01 (8), Stats.:
DHS 107.07(1)(j)3.
3. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation.
DHS 107.07 Note
Note: Orthodontia may be covered under early and periodic screening, diagnosis and treatment (EPSDT) services. Please see s.
DHS 107.22 (4).
DHS 107.07(1m)
(1m) Covered services; dental hygienists. Except as provided under subs.
(2),
(3),
(4), and
(4m), all of the following dental services are covered services when provided by a dental hygienist who is individually certified under ch.
DHS 105 within the scope of dental hygiene as defined in s.
447.01 (3), Stats.:
DHS 107.07(2)(a)(a) All of the following dental services require prior authorization in order to be reimbursed under MA:
