DHS 107.16(3)(c)2.
2. The specialized knowledge and judgment of a physical 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 necessary re-evaluations; or
DHS 107.16(3)(c)3.
3. When, due to the severity or complexity of the recipient's condition, nursing personnel cannot handle the recipient safely and effectively.
DHS 107.16(3)(d)
(d) 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 107.16(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 107.16(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 107.16(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 107.16(3)(e)3.
3. The recipient has achieved independence in daily activities or can be supervised and assisted by restorative nursing personnel;
DHS 107.16(3)(e)4.
4. The evaluation indicates that the recipient's abilities are functional for the person's present way of life;
DHS 107.16(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 107.16(3)(e)6.
6. Other therapies are providing sufficient services to meet the recipient's functioning needs; or
DHS 107.16(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 107.16(3)(f)
(f)
Group physical therapy. Group physical therapy shall be a covered service. For purposes of this paragraph, “group physical therapy” means a physical therapy session at which there are more than one but not more than 10 recipients receiving services together from one or 2 providers. No more than 2 providers may be reimbursed for the same session. Physical therapy aides may not be reimbursed for group physical therapy.
DHS 107.16(4)
(4) Non-covered services. The following services are not covered services:
DHS 107.16(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 107.16(4)(c)
(c) 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 107.16(4)(e)
(e) When performed by a physical therapy aide, interpretation of physician referrals, patient evaluation, evaluation of procedures, initiation or adjustment of treatment, assumption of responsibility for planning patient care, or making entries in patient records.
DHS 107.16 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.16 History
History: Cr.
Register, February, 1986, No 362, eff. 3-1-86; emerg. am. (2) (b), (d), (g), (3) (d) and (e) (intro.), eff. 7-1-88; am. (2) (b), (d), (g), (3) (d) and (e) (intro.),
Register, December, 1988, No. 396, eff. 1-1-89; correction in (4) (b) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
2021Wis. Act 225: cr. (3) (f), r. (4) (d)
Register April 2022 No. 796, eff. 4-10-22;
CR 22-043: am. (1) (a), renum. (1) (e) 3. a. to (1) (e) 3. and am., r. (1) (e) 3. b.
Register May 2023 No. 809, eff. 6-1-23.
DHS 107.17(1)(1)
Covered services. Covered occupational therapy services are the following medically necessary services when prescribed by a physician and performed by a certified occupational therapist (OT) or by a certified occupational therapist assistant (COTA) under the direct, immediate, on-premises supervision of a certified occupational therapist or, for services under par.
(d), by a certified occupational therapist assistant under the general supervision of a certified occupational therapist pursuant to the requirements of s.
DHS 105.28 (2):
DHS 107.17(1)(j)
(j) Evaluations or re-evaluations. Covered evaluations, the results of which shall be set out in a written report attached to the test chart or form in the recipient's medical record, are the following:
