Chapter DHS 107

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)(a) (a) Motor skills, as follows:

DHS 107.17(1)(a)1. 1. Range-of-motion;

DHS 107.17(1)(a)2. 2. Gross/fine coordination;

DHS 107.17(1)(a)3. 3. Strengthening;

DHS 107.17(1)(a)4. 4. Endurance/tolerance; and

DHS 107.17(1)(a)5. 5. Balance;

DHS 107.17(1)(b) (b) Sensory integrative skills, as follows:

DHS 107.17(1)(b)1. 1. Reflex/sensory status;

DHS 107.17(1)(b)2. 2. Body concept;

DHS 107.17(1)(b)3. 3. Visual-spatial relationships;

DHS 107.17(1)(b)4. 4. Posture and body integration; and

DHS 107.17(1)(b)5. 5. Sensorimotor integration;

DHS 107.17(1)(c) (c) Cognitive skills, as follows:

DHS 107.17(1)(c)1. 1. Orientation;

DHS 107.17(1)(c)2. 2. Attention span;

DHS 107.17(1)(c)3. 3. Problem-solving;

DHS 107.17(1)(c)4. 4. Conceptualization; and

DHS 107.17(1)(c)5. 5. Integration of learning;

DHS 107.17(1)(d) (d) Activities of daily living skills, as follows:

DHS 107.17(1)(d)1. 1. Self-care;

DHS 107.17(1)(d)2. 2. Work skills; and

DHS 107.17(1)(d)3. 3. Avocational skills;

DHS 107.17(1)(e) (e) Social interpersonal skills, as follows:

DHS 107.17(1)(e)1. 1. Dyadic interaction skills; and

DHS 107.17(1)(e)2. 2. Group interaction skills;

DHS 107.17(1)(f) (f) Psychological intrapersonal skills, as follows:

DHS 107.17(1)(f)1. 1. Self-identity and self-concept;

DHS 107.17(1)(f)2. 2. Coping skills; and

DHS 107.17(1)(f)3. 3. Independent living skills;

DHS 107.17(1)(g) (g) Preventive skills, as follows:

DHS 107.17(1)(g)1. 1. Energy conservation;

DHS 107.17(1)(g)2. 2. Joint protection;

DHS 107.17(1)(g)3. 3. Edema control; and

DHS 107.17(1)(g)4. 4. Positioning;

DHS 107.17(1)(h) (h) Therapeutic adaptions, as follows:

DHS 107.17(1)(h)1. 1. Orthotics/splinting;

DHS 107.17(1)(h)2. 2. Prosthetics;

DHS 107.17(1)(h)3. 3. Assistive/adaptive equipment; and

DHS 107.17(1)(h)4. 4. Environmental adaptations;

DHS 107.17(1)(i) (i) Environmental planning; and

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:

DHS 107.17(1)(j)1. 1. Motor skills:

DHS 107.17(1)(j)1.a. a. Range-of-motion;

DHS 107.17(1)(j)1.b. b. Gross muscle test;

DHS 107.17(1)(j)1.c. c. Manual muscle test;

DHS 107.17(1)(j)1.d. d. Coordination evaluation;

DHS 107.17(1)(j)1.e. e. Nine hole peg test;

DHS 107.17(1)(j)1.f. f. Purdue pegboard test;

DHS 107.17(1)(j)1.g. g. Strength evaluation;

DHS 107.17(1)(j)1.h. h. Head-trunk balance evaluation;

DHS 107.17(1)(j)1.i. i. Standing balance — endurance;

DHS 107.17(1)(j)1.j. j. Sitting balance — endurance;

DHS 107.17(1)(j)1.k. k. Prosthetic check-out;

DHS 107.17(1)(j)1.L. L. Hemiplegic evaluation;

DHS 107.17(1)(j)1.m. m. Arthritis evaluation; and

DHS 107.17(1)(j)1.n. n. Hand evaluation — strength and range-of-motion;

DHS 107.17(1)(j)2. 2. Sensory integrative skills:

DHS 107.17(1)(j)2.a. a. Beery test of visual motor integration;

DHS 107.17(1)(j)2.b. b. Southern California kinesthesia and tactile perception test;

DHS 107.17(1)(j)2.c. c. A. Milloni-Comparetti developmental scale;

DHS 107.17(1)(j)2.d. d. Gesell developmental scale;

DHS 107.17(1)(j)2.e. e. Southern California perceptual motor test battery;

DHS 107.17(1)(j)2.f. f. Marianne Frostig developmental test of visual perception;

DHS 107.17(1)(j)2.g. g. Reflex testing;

DHS 107.17(1)(j)2.h. h. Ayres space test;

DHS 107.17(1)(j)2.i. i. Sensory evaluation;

DHS 107.17(1)(j)2.j. j. Denver developmental test;

DHS 107.17(1)(j)2.k. k. Perceptual motor evaluation; and

DHS 107.17(1)(j)2.L. L. Visual field evaluation;

DHS 107.17(1)(j)3. 3. Cognitive skills:

DHS 107.17(1)(j)3.a. a. Reality orientation assessment; and

DHS 107.17(1)(j)3.b. b. Level of cognition evaluation;

DHS 107.17(1)(j)4. 4. Activities of daily living skills:

DHS 107.17(1)(j)4.a. a. Bennet hand tool evaluation;

DHS 107.17(1)(j)4.b. b. Crawford small parts dexterity test;

DHS 107.17(1)(j)4.c. c. Avocational interest and skill battery;

DHS 107.17(1)(j)4.d. d. Minnesota rate of manipulation; and

DHS 107.17(1)(j)4.e. e. ADL evaluation \ men and women;

DHS 107.17(1)(j)5. 5. Social interpersonal skills — evaluation of response in group;

DHS 107.17(1)(j)6. 6. Psychological intrapersonal skills:

DHS 107.17(1)(j)6.a. a. Subjective assessment of current emotional status;

DHS 107.17(1)(j)6.b. b. Azima diagnostic battery; and

DHS 107.17(1)(j)6.c. c. Goodenough draw-a-man test;

DHS 107.17(1)(j)7. 7. Therapeutic adaptions; and

DHS 107.17(1)(j)8. 8. Environmental planning — environmental evaluation.

DHS 107.17(2) (2) Services requiring prior authorization.

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.