DHS 107.113(5)(g)2.b.
b. Failure to provide skilled nursing services likely would result in serious impairment of the recipient's health.
DHS 107.113 History
History: Cr.
Register, February, 1993, No. 446, eff. 3-1-93; correction in (4) (c) made under s. 13.93 (2m) (b) 7., Stats.,
Register, April, 1999, No. 520;
CR 05-052: r. and recr. (5) (d), cr. (5) (g)
Register June 2007 No. 618, eff. 7-1-07; corrections in (1) (intro.), (3) and (4) (b) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 23-046: r. and recr. (1), am. (2) (intro.), (a), (3) (a), (4) (f) Register April 2024 No. 820, eff. 5-1-24; correction in (1) (b) 2. made under s. 35.17, Stats., correction in numbering of (1) (d) 4. a. to c. made under s. 13.92 (4) (b) 7., Stats., and (3) (a) renumbered (3) under s. 13.92 (4) (b) 1., Stats., Register April 2024 No. 820. DHS 107.12
DHS 107.12
Private duty nursing services. DHS 107.12(1)(a)(a) Private duty nursing is skilled nursing care available for recipients with medical conditions requiring more continuous skilled care than can be provided on a part-time, intermittent basis. Only a recipient who requires 8 or more hours of skilled nursing care and is authorized to receive these services in the home setting may make use of the approved hours outside of that setting during those hours when normal life activities take him or her outside of that setting. Private duty nursing may be provided according to the requirements under ss.
DHS 105.16 and
105.19 when the written plan of care specifies the medical necessity for this type of service.
DHS 107.12(1)(b)
(b) Private duty nursing services provided by a certified registered nurse in independent practice are those services prescribed by a provider acting within the scope of the provider's practice which comprise the practice of professional nursing as described under s.
441.001 (4), Stats., and s.
N 6.03. Private duty nursing services provided by a certified licensed practical nurse are those services which comprise the practice of practical nursing under s.
441.001 (3), Stats., and s.
N 6.04. An LPN may provide private duty nursing services delegated by a registered nurse as delegated nursing acts under the requirements of ch.
N 6 and guidelines established by the state board of nursing.
DHS 107.12(1)(c)
(c) Services may be provided only when prescribed by a provider acting within the scope of the provider's practice and the prescription calls for a level of care which the nurse is licensed and competent to provide.
DHS 107.12(1)(d)1.1. A written plan of care, including a functional assessment, medication and treatment orders, shall be established for every recipient admitted for care and shall be incorporated in the recipient's medical record within 72 hours after acceptance in consultation with the recipient and the recipient's provider acting within the scope of the provider's practice and shall be signed by the provider within 20 working days following the recipient's admission for care. The provider's plan of care shall include, in addition to the medication and treatment orders:
DHS 107.12(1)(d)1.b.
b. Methods for delivering needed care, and an indication of which other professional disciplines, if any, are responsible for delivering the care;
DHS 107.12(1)(d)1.c.
c. Provision for care coordination by an RN when more than one nurse is necessary to staff the recipient's case; and
DHS 107.12(1)(d)1.d.
d. A description of functional capability, mental status, dietary needs and allergies.
DHS 107.12(1)(d)2.
2. The written plan of care shall be reviewed and signed by the recipient's provider acting within the scope of the provider's practice as often as required by the recipient's condition, but not less often than every 62 days. The RN shall promptly notify the provider of any change in the recipient's condition that suggests a need to modify the plan of care.
DHS 107.12(1)(e)1.1. Except as provided in subd.
2., drugs and treatment shall be administered by the RN or LPN only as ordered by the recipient's provider acting within the scope of the provider's practice or his or her designee. The nurse shall immediately record and sign oral orders and shall obtain the provider's countersignature within 10 working days.
DHS 107.12(1)(f)
(f) Medically necessary actual time spent in direct care that requires the skills of a licensed nurse is a covered service.
DHS 107.12(2)(a)
(a) Prior authorization is required for all private duty nursing services.
DHS 107.12(2)(c)
(c) A request for prior authorization of private duty nursing services performed by an LPN shall include the name and license number of the registered nurse or physician supervising the LPN.
DHS 107.12(2)(d)
(d) A request for prior authorization for care for a recipient who requires more than one private duty nurse to provide medically necessary care shall include the name and license number of the RN performing care coordination responsibilities.
DHS 107.12(3)(b)
(b) An RN supervising an LPN performing services under this section shall supervise the LPN as often as necessary under the requirements of s.
N 6.03 during the period the LPN is providing services, and shall communicate the results of supervisory activities to the LPN. These activities shall be documented by the RN.
DHS 107.12(3)(c)
(c) Each private duty nurse shall document the nature and scope of the care and services provided to the recipient in the recipient's medical record.
DHS 107.12(3)(e)
(e) Travel time, recordkeeping and RN supervision of an LPN are not separately reimbursable services.
DHS 107.12(4)
(4) Non-covered services. The following services are not covered services:
DHS 107.12(4)(c)
(c) Skilled nursing services performed by a recipient's spouse or parent if the recipient is under age 21;
DHS 107.12(4)(e)
(e) Any service that fails to meet the recipient's medical needs or places the recipient at risk for a negative treatment outcome.
DHS 107.12(4)(f)1.1. Except as provided in subd.
2., services provided by an individual nurse under this section that, when combined with services provided to all recipients and other patients under the nurse's care, exceed either of the following limitations:
DHS 107.12(4)(f)2.
2. Services may exceed the limitations in subd.
1. when both of the following conditions are met:
DHS 107.12(4)(f)2.a.
a. The services are approved by the department on a case-by-case basis for circumstances that could not reasonably have been predicted.
DHS 107.12(4)(f)2.b.
b. Failure to provide skilled nursing services likely would result in serious impairment of the recipient's health.
DHS 107.12(4)(g)1.1. Except as provided in subd.
2., services provided during any 24-hour period during which the nurse who performs the services has less than 8 continuous and uninterrupted hours off duty.
DHS 107.12(4)(g)2.
2. Services may exceed the limitations in subd.
1. when both of the following conditions are met:
DHS 107.12(4)(g)2.a.
a. The services are approved by the department on a case-by-case basis for circumstances that could not reasonably have been predicted.
DHS 107.12(4)(g)2.b.
b. Failure to provide skilled nursing services likely would result in serious impairment of the recipient's health.
DHS 107.12 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. eff. 7-1-90; r. and recr.
Register, January, 1991, No. 421, eff. 2-1-91; emerg. r. and recr. eff. 7-1-92; r. and recr.
Register, February, 1993, No. 446, eff. 3-1-93;
CR 03-033: am. (1) (e)
Register December 2003 No. 576, eff. 1-1-04; corrections in (1) (b) made under s. 13.93 (2m) (b) 7., Stats.,
Register December 2003 No. 576;
CR 05-052: r. (2) (b) and (3) (d), cr. (4) (f) and (g)
Register June 2007 No. 618, eff. 7-1-07; corrections in (1) (a) and (3) (a) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 23-046: am. (1) (b), (c), (d) 1. (intro.), 2., (e) 1., (4) (a) Register April 2024 No. 820, eff. 5-1-24. DHS 107.121(1)(1)
Covered services. Covered services provided by a certified nurse-midwife may include the care of mothers and their babies throughout the maternity cycle, including pregnancy, labor, normal childbirth and the immediate postpartum period, provided that the nurse-midwife services are provided within the limitations established in s.
441.15 (2), Stats., and ch.
N 4.
DHS 107.121(2)
(2) Limitation. Coverage for nurse-midwife services for management and care of the mother and newborn child shall end after the sixth week of postpartum care.
DHS 107.121 History
History: Cr.
Register, January, 1991, No. 421, eff. 2-1-91.
DHS 107.122
DHS 107.122
Independent nurse practitioner services. DHS 107.122(1)(1)
Covered services. Services provided by a nurse practitioner, including a clinical nurse specialist, which are covered by the MA program are those medical services delegated by a licensed physician by a written protocol developed with the nurse practitioner pursuant to the requirements set forth in s.
N 6.03 (2) and guidelines set forth by the medical examining board and the board of nursing. General nursing procedures are covered services when performed by a certified nurse practitioner or clinical nurse specialist in accordance with the requirements of s.
N 6.03 (1). These services may include those medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a medical setting, the recipient's home or elsewhere. Specific reimbursable delegated medical acts and nursing services are the following:
DHS 107.122(1)(a)1.
1. Obtaining a recipient's complete health history and recording the findings in a systematic, organized manner;
DHS 107.122(1)(a)3.
3. Performing a complete physical assessment using techniques of observation, inspection, auscultation, palpation and percussion, ordering appropriate laboratory and diagnostic tests and recording findings in a systematic manner;
DHS 107.122(1)(a)4.
4. Performing and recording a developmental or functional status evaluation and mental status examination using standardized procedures; and
DHS 107.122(1)(a)5.
5. Identifying and describing behavior associated with developmental processes, aging, life style and family relationships;
DHS 107.122(1)(b)1.
1. Discriminating between normal and abnormal findings associated with growth and development, aging and pathological processes;
DHS 107.122(1)(b)2.
2. Discriminating between normal and abnormal patterns of behavior associated with developmental processes, aging, life style, and family relationships as influenced by illness;
DHS 107.122(1)(b)3.
3. Exercising clinical judgment in differentiating between situations which the nurse practitioner can manage and those which require consultations or referral; and
DHS 107.122(1)(c)1.
1. Providing preventive health care and health promotion for adults and children;
DHS 107.122(1)(c)2.
2. Managing common self-limiting or episodic health problems in recipients according to protocol and other guidelines;
DHS 107.122(1)(c)3.
3. Managing stabilized illness problems in coloration with physicians and other health care providers according to protocol;
DHS 107.122(1)(c)4.
4. Prescribing, regulating and adjusting medications as defined by protocol;
DHS 107.122(1)(c)6.
6. Counseling recipients and their families about the process of growth and development, aging, life crises, common illnesses, risk factors and accidents;
DHS 107.122(1)(c)7.
7. Helping recipients and their families assume greater responsibility for their own health maintenance and illness care by providing instruction, counseling and guidance;
DHS 107.122(1)(c)8.
8. Arranging referrals for recipients with health problems who need further evaluation or additional services; and
DHS 107.122(1)(c)9.
9. Modifying the therapeutic regimen so that it is appropriate to the developmental and functional statuses of the recipient and the recipient's family;
DHS 107.122(1)(d)2.
2. Collecting systematic data for evaluating the response of a recipient and the recipient's family to a therapeutic regimen;
DHS 107.122(1)(d)5.
5. Utilizing an epidemiological approach in examining the health care needs of recipients in the nurse practitioner's caseload;
DHS 107.122(2)(a)
(a) Services under sub.
(1) (e) to
(k) are subject to applicable prior authorization requirements for those services.
DHS 107.122(2)(b)
(b) Requests for prior authorization shall be accompanied by the written protocol.
