This is the preview version of the Wisconsin State Legislature site.
Please see http://docs.legis.wisconsin.gov for the production version.
Alert! This chapter may be affected by an emergency rule:
(7)Psychosocial services provided through a community-based psychosocial service program.
(a) Covered services. Psychosocial services provided through a community-based psychosocial service program shall be covered services when authorized by a mental health professional under s. DHS 36.15 for recipients determined to have a need for the services under s. DHS 36.14. These non-institutional services must fall within the definition of “rehabilitative services” under 42 CFR 440.130 (d) and must be described in a service plan under s. DHS 36.17. Covered services include assessment under s. DHS 36.16 and service planning and review under s. DHS 36.17.
(b) Other limitations.
1. Mental health services under s. DHS 107.13 (2) and (4) are not reimbursable for recipients receiving services under this subsection.
2. Group psychotherapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group psychotherapy. Mental health technicians shall not be reimbursed for group psychotherapy.
3. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub. (6).
(c) Non-covered services. The following are not covered services under this subsection:
1. Case management services provided under s. DHS 107.32 by a provider not certified under s. DHS 105.257 to provide services under this section.
2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community.
3. Services performed by volunteers, except that out-of-pocket expenses incurred by volunteers in performing services may be covered.
4. Services that are not rehabilitative, including services that are primarily recreation-oriented.
5. Legal advocacy performed by an attorney or paralegal.
History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (f) 8., Register, February, 1988, No. 386, eff. 3-1-88; emerg. cr. (3m), eff. 3-9-89; cr. (3m), Register, December, 1989, No. 408, eff. 1-1-90; emerg. cr. (2) (c) 5., (3) (c) 2., (4) (c) 4. and (6), eff. 1-1-90; cr. (2) (c) 5., (3) (c) 2., (4) (c) 4. and (6), Register, September, 1990, No. 417, eff. 10-1-90; emerg. r. and recr. (1) (b) 3., am. (1) (f) 6., eff. 1-1-91; am. (1) (a), (b) 1. and 2., (c), (f) 5., 6. and 8., (2) (a) 1., 3. a. and b., 4. f., 6., 7., (b) 1. and 2., (c) 2., (3) (a) (intro.), 4., 5., 7., (b) 1. and 2., (c) 1. (3) (d) 1. and 2., (4) (a) 3. and 6. and (d) 6., r. and recr. (1) (b) 3. and (e), r. (4) (b) 1. d., renum. (4) (b) 1. c. to be d., cr. (2) (c) 6., (3) (c) 3. and 4., (3) (d) 3., Register, September, 1991, No. 429, eff. 10-1-91; am. (4) (a) 2., cr. (4) (a) 8., Register, February, 1993, No. 446, eff. 3-1-93; corrections in (3) (d) 3. and (3m) (a) 1. made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; emerg. am. (2) (c) 5. and (4) (c) 4., cr. (6) (b) 4. and (7), eff. 7-1-04; CR 04-025: am (2) (c) 5. and (4) (c) 4., cr. (6) (b) 4. and (7) Register October 2004 No. 586, eff. 11-1-04; corrections in (1) (a), (f) 5., (2) (a) (intro.), 3., (c) 6., (3) (a) (intro.), (c) 3., (d) 3., (3m) (a) (intro.), 1., (b) 3., (4) (a) (intro.), 8., (6) (a) (intro.), (c) 1., (7) (a) and (c) 1. made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 06-080: am. (2) (a) (intro.), 1. (intro.), 3. a., b., 4. a. to f., 6., 7., (b) 1., 4. a. to d., (c) 4., 6. and (d) 2., cr. (2) (a) 1. a. to g. and (2m) Register May 2009 No. 641, eff. 6-1-09; CR 14-066: am. (2) (a) (intro.), r. (2) (a) 2., am. (2) (a) 4. (intro.), cr. (2) (a) 4. g., r. (2) (b) 4. b., am. (2) (d) (intro.), 1. to. 4. Register August 2015 No. 716, eff. 9-1-15; 2019 Wis. Act 1: am. (2) (d) 2. Register May 2019 No. 761; eff. 6-1-19; CR 20-039: am. (2) (d) 1. Register October 2021 No. 790, eff. 11-1-21; correction in (6) (c) 2. made under s. 35.17, Stats., Register July 2022 No. 799; correction in (3) (d) 3., (3m) (a) 1. made under s. 13.92 (4) (b) 7., Stats., made under s. 13.92 (4) (b) 7., Stats., Register September 2022 No. 801; CR 22-043: cr. (2) (a) 4. h., am. (2) (a) 5., (b) 4. e., (3) (a) 5., 6., (b) 4. d., (3m) (d) 6., (4) (a) 8., (d) 7. Register May 2023 No. 809, eff. 6-1-23; correction in (2) (a) 5., (3) (a) 6. made under s. 35.17, Stats., Register May 2023 No. 809; CR 23-046: r. (2) (a) 6., 7., (b), (3) (a) 4., 7., (b) Register April 2024 No. 820, eff. 5-1-24; correction in (2) (a) 5., (3) (a) 6. made under s. 35.17, Stats., Register April 2024 No. 820.
DHS 107.14Podiatry services.
(1)Covered services.
(a) Podiatry services covered by medical assistance are those medically necessary services for the diagnosis and treatment of the feet and ankles, within the limitations described in this section, when provided by a certified podiatrist.
(b) The following categories of services are covered services when performed by a podiatrist:
1. Office visits;
2. Home visits;
3. Nursing home visits;
4. Physical medicine;
6. Mycotic conditions and nails;
7. Laboratory;
8. Radiology;
9. Plaster or other cast material used in cast procedures and strapping or tape casting for treating fractures, dislocations, sprains and open wounds of the ankle, foot and toes;
10. Unna boots; and
11. Drugs and injections.
(2)Other limitations.
(a) Podiatric services pertaining to the cleaning, trimming and cutting of toenails, often referred to as palliative or maintenance care, shall be reimbursed once per 61 day period only if the recipient is under the active care of a physician and the recipient’s condition is one of the following:
1. Diabetes mellitus;
2. Arteriosclerosis obliterans evidenced by claudication;
3. Peripheral neuropathies involving the feet, which are associated with:
a. Malnutrition or vitamin deficiency;
b. Diabetes mellitus;
c. Drugs and toxins;
d. Multiple sclerosis; or
4. Cerebral palsy;
5. Multiple sclerosis;
6. Spinal cord injuries;
7. Blindness;
8. Parkinson’s disease;
9. Cerebrovascular accident; or
10. Scleroderma.
(b) The cutting, cleaning and trimming of toenails, corns, callouses and bunions on multiple digits shall be reimbursed at one fee for each service which includes either one or both feet.
(c) Initial diagnostic services are covered when performed in connection with a specific symptom or complaint if it seems likely that treatment would be covered even though the resulting diagnosis may be one requiring non-covered care.
(d) Physical medicine modalities may include, but are not limited to, hydrotherapy, ultrasound, iontophoresis, transcutaneous neurostimulator (TENS) prescription, and electronic bone stimulation. Physical medicine is limited to 10 modality services per calendar year for the following diagnoses only:
1. Osteoarthritis;
2. Tendinitis;
3. Enthesopathy;
4. Sympathetic reflex dystrophy;
5. Subclacaneal bursitis; and
6. Plantar fascitis, as follows:
b. Capsulitis;
c. Bursitis; or
(e) Services provided during a nursing home visit to cut, clean or trim toenails, corns, callouses or bunions of more than one resident shall be reimbursed at the nursing home single visit rate for only one of the residents seen on that day of service. All other claims for residents seen at the nursing home on the same day of service shall be reimbursed up to the multiple nursing home visit rate. The podiatrist shall identify on the claim form the single resident for whom the nursing home single visit rate is applicable, and the residents for whom the multiple nursing home visit rate is applicable.
(f) Debridement of mycotic conditions and mycotic nails is a covered service provided that utilization guidelines established by the department are followed.
(3)Non-covered services. The following are not covered services:
(a) Procedures which do not relate to the diagnosis or treatment of the ankle or foot;
(b) Palliative or maintenance care, except under sub. (2);
(c) All orthopedic and orthotic services except plaster and other material cast procedures and strapping or tape casting for treating fractures, dislocations, sprains or open wounds of the ankle, foot or toes;
(d) Orthopedic shoes and supportive devices such as arch supports, shoe inlays and pads;
(e) Physical medicine exceeding the limits specified under sub. (2) (d);
(f) Repairs made to orthopedic and orthotic appliances;
(g) Dispensing and repairing corrective shoes;
(h) Services directed toward the care and correction of “flat feet;”
(i) Treatment of subluxation of the foot; and
(j) All other services not specifically identified as covered in this section.
History: Emerg. cr. eff. 7-1-90; cr. Register, January, 1991, No. 421, eff. 2-1-91.
DHS 107.15Chiropractic services.
(1)Definition. In this section, “spell of illness” means a condition characterized by the onset of a spinal subluxation.“Subluxation” means the alteration of the normal dynamics, anatomical or physiological relationships of contiguous articular structures. A subluxation may have biomechanical, pathophysiological, clinical, radiologic and other manifestations.
(2)Covered services. Chiropractic services covered by MA are manual manipulations of the spine used to treat a subluxation. These services shall be performed by a chiropractor certified pursuant to s. DHS 105.26.
(3)Services requiring prior authorization.
(a) Requirement.
1. Prior authorization is required for services beyond the initial visit and 20 spinal manipulations per spell of illness. The prior authorization request shall include a justification of why the condition is chronic and why it warrants the scope of service being requested.
2. Prior authorization is required for spinal supports which have been prescribed by a physician or chiropractor if the purchase or rental price of a support is over $75. Rental costs under $75 shall be paid for one month without prior approval.
(b) Conditions justifying spell of illness designation. The following conditions may justify designation of a new spell of illness if treatment for the condition is medically necessary:
1. An acute onset of a new spinal subluxation;
2. An acute onset of an aggravation of pre-existing spinal subluxation by injury; or
3. An acute onset of a change in pre-existing spinal subluxation based on objective findings.
(c) Onset and termination of spell of illness. The spell of illness begins with the first day of treatment or evaluation following the onset of a condition under par. (b) and ends when the recipient improves so that treatment by a chiropractor for the condition causing the spell of illness is no longer medically necessary, or after 20 spinal manipulations, whichever comes first.
(d) Documentation. The chiropractor shall document the spell of illness in the patient plan of care.
(e) Non-transferability of treatment days. Unused treatment days from one spell of illness shall not be carried over into a new spell of illness.
(f) Other coverage. Treatment days covered by medicare or other third-party insurance shall be included in computing the 20 spinal manipulation per spell of illness total.
(g) Department expertise. The department may have on its staff qualified chiropractors to develop prior authorization criteria and perform other consultative activities.
Note: For more information on prior authorization, see s. DHS 107.02 (3).
Loading...
Loading...
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.