Chapter DHS 107

DHS 107.17(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 107.17(4) (4) Non-covered services. The following services are not covered services:

DHS 107.17(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 107.17(4)(b) (b) Services that can be performed by restorative nursing, as under s. DHS 132.60 (1) (b) to (d);

DHS 107.17(4)(c) (c) Crafts and other supplies used in occupational therapy services for inpatients in an institutional program. These are not billable by the therapist; and

DHS 107.17(4)(d) (d) 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 107.17 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.17 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. am. (2) (b), (d), (g), (3) (c) and (e) (intro.), eff. 7-1-88; am. (2) (b) (d), (g) (3) (c) and (e) (intro.), Register, December, 1988, No. 396, eff. 1-1-89; corrections in (1) (intro.) and (4) (b) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.18 DHS 107.18 Speech and language pathology services.

DHS 107.18(1) (1) Covered services.

DHS 107.18(1)(a) (a) General. Covered speech and language pathology services are those medically necessary diagnostic, screening, preventive or corrective speech and language pathology services prescribed by a physician and provided by a certified speech and language pathologist or under the direct, immediate on-premises supervision of a certified speech and language pathologist.

DHS 107.18(1)(b) (b) Evaluation procedures. Evaluation or re-evaluation procedures shall be performed by certified speech and language pathologists. Tests and measurements that speech and language pathologists may perform include the following:

DHS 107.18(1)(b)1. 1. Expressive language:

DHS 107.18(1)(b)1.a. a. Aphasia evaluation (examples of tests are Eisenson, PICA, Schuell);

DHS 107.18(1)(b)1.b. b. Articulation evaluation (examples of tests are Arizona articulation, proficiency scale, Goldman-Fristoe test of articulation, Templin-Darley screening and diagnostic tests of articulation);

DHS 107.18(1)(b)1.c. c. Cognitive assessment (examples are tests of classification, conservation, Piagetian concepts);

DHS 107.18(1)(b)1.d. d. Language concept evaluation (examples are tests of temporal, spatial, and quantity concepts, environmental concepts, and the language of direction);

DHS 107.18(1)(b)1.e. e. Morphological evaluation (examples are the Miller-Yoder test and the Michigan inventory);

DHS 107.18(1)(b)1.f. f. Question evaluation — yes-no, is-are, where, who, why, how and when;

DHS 107.18(1)(b)1.g. g. Stuttering evaluation;

DHS 107.18(1)(b)1.h. h. Syntax evaluation;

DHS 107.18(1)(b)1.i. i. Vocabulary evaluation;

DHS 107.18(1)(b)1.j. j. Voice evaluation;

DHS 107.18(1)(b)1.k. k. Zimmerman pre-school language scale; and

DHS 107.18(1)(b)1.L. L. Illinois test of psycholinguistic abilities;

DHS 107.18(1)(b)2. 2. Receptive language:

DHS 107.18(1)(b)2.a. a. ACLC or assessment of children’s language comprehension;

DHS 107.18(1)(b)2.b. b. Aphasia evaluation (examples of tests are Eisenson, PICA, Schuell);

DHS 107.18(1)(b)2.c. c. Auditory discrimination evaluation (examples are the Goldman-Fristoe-Woodcock test of auditory discrimination and the Wepman test of auditory discrimination);

DHS 107.18(1)(b)2.d. d. Auditory memory (an example is Spencer-MacGrady memory for sentences test);

DHS 107.18(1)(b)2.e. e. Auditory processing evaluation;

DHS 107.18(1)(b)2.f. f. Cognitive assessment (examples are tests of one-to-one correspondence, and seriation classification conservation);

DHS 107.18(1)(b)2.g. g. Language concept evaluation (an example is the Boehm test of basic concepts);

DHS 107.18(1)(b)2.h. h. Morphological evaluation (examples are Bellugi-Klima grammatical comprehension tests, Michigan inventory, Miller-Yoder test);

DHS 107.18(1)(b)2.i. i. Question evaluation;

DHS 107.18(1)(b)2.j. j. Syntax evaluation;

DHS 107.18(1)(b)2.k. k. Visual discrimination evaluation;

DHS 107.18(1)(b)2.L. L. Visual memory evaluation;

DHS 107.18(1)(b)2.m. m. Visual sequencing evaluation;

DHS 107.18(1)(b)2.n. n. Visual processing evaluation;

DHS 107.18(1)(b)2.o. o. Vocabulary evaluation (an example is the Peabody picture vocabulary test);

DHS 107.18(1)(b)2.p. p. Zimmerman pre-school language scale; and

DHS 107.18(1)(b)2.q. q. Illinois test of psycholinguistic abilities;

DHS 107.18(1)(b)3. 3. Pre-school speech skills:

DHS 107.18(1)(b)3.a. a. Diadochokinetic rate evaluation; and

DHS 107.18(1)(b)3.b. b. Oral peripheral evaluation; and

DHS 107.18(1)(b)4. 4. Hearing-auditory training:

DHS 107.18(1)(b)4.a. a. Auditory screening;

DHS 107.18(1)(b)4.b. b. Informal hearing evaluation;

DHS 107.18(1)(b)4.c. c. Lip-reading evaluation;

DHS 107.18(1)(b)4.d. d. Auditory training evaluation;

DHS 107.18(1)(b)4.e. e. Hearing-aid orientation evaluation; and

DHS 107.18(1)(b)4.f. f. Non-verbal evaluation.

DHS 107.18(1)(c) (c) Speech procedure treatments. The following speech procedure treatments shall be performed by a certified speech and language pathologist or under the direct, immediate, on-premises supervision of a certified speech and language pathologist:

DHS 107.18(1)(c)1. 1. Expressive language:

DHS 107.18(1)(c)1.a. a. Articulation;

DHS 107.18(1)(c)1.b. b. Fluency;

DHS 107.18(1)(c)1.c. c. Voice;

DHS 107.18(1)(c)1.d. d. Language structure, including phonology, morphology, and syntax;

DHS 107.18(1)(c)1.e. e. Language content, including range of abstraction in meanings and cognitive skills; and

DHS 107.18(1)(c)1.f. f. Language functions, including verbal, non-verbal and written communication;

DHS 107.18(1)(c)2. 2. Receptive language:

DHS 107.18(1)(c)2.a. a. Auditory processing — attention span, acuity or perception, recognition, discrimination, memory, sequencing and comprehension; and

DHS 107.18(1)(c)2.b. b. Visual processing — attention span, acuity or perception, recognition, discrimination, memory, sequencing and comprehension;

DHS 107.18(1)(c)3. 3. Pre-speech skills:

DHS 107.18(1)(c)3.a. a. Oral and peri-oral structure;

DHS 107.18(1)(c)3.b. b. Vegetative function of the oral motor skills; and

DHS 107.18(1)(c)3.c. c. Volitional oral motor skills; and

DHS 107.18(1)(c)4. 4. Hearing/auditory training:

DHS 107.18(1)(c)4.a. a. Hearing screening and referral;

DHS 107.18(1)(c)4.b. b. Auditory training;

DHS 107.18(1)(c)4.c. c. Lip reading;

DHS 107.18(1)(c)4.d. d. Hearing aid orientation; and

DHS 107.18(1)(c)4.e. e. Non-verbal communication.

DHS 107.18(2) (2) Services requiring prior authorization.

DHS 107.18(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 107.18(2)(b) (b) Requirement. Prior authorization is required under this subsection for speech and language pathology services provided to an MA recipient in excess of 35 treatment days per spell of illness, except that speech and language pathology services provided to an MA recipient who is a hospital inpatient or who is receiving speech therapy services provided by a home health agency are not subject to prior authorization under this subsection.

DHS 107.18 Note Note: Speech and language pathology services provided by a home health agency are subject to prior authorization under s. DHS 107.11 (3).

DHS 107.18(2)(c) (c) Conditions justifying spell of illness designation. The following conditions may justify designation of a new spell of illness:

DHS 107.18(2)(c)1. 1. An acute onset of a new disease, injury or condition such as:

DHS 107.18(2)(c)1.a. a. Neuromuscular dysfunction, including stroke-hemiparesis, multiple sclerosis, Parkinson’s disease and diabetic neuropathy;

DHS 107.18(2)(c)1.b. b. Musculoskeletal dysfunction, including fracture, amputation, strains and sprains, and complications associated with surgical procedures; or

DHS 107.18(2)(c)1.c. c. Problems and complications associated with physiologic dysfunction, including severe pain, vascular conditions, and cardio-pulmonary conditions;

DHS 107.18(2)(c)2. 2. An exacerbation of a pre-existing condition including but not limited to the following, which requires speech therapy intervention on an intensive basis:

DHS 107.18(2)(c)2.a. a. Multiple sclerosis;

DHS 107.18(2)(c)2.b. b. Rheumatoid arthritis; or

DHS 107.18(2)(c)2.c. c. Parkinson’s disease; or

DHS 107.18(2)(c)3. 3. A regression in the recipient’s condition due to lack of speech therapy, as indicated by a decrease of functional ability, strength, mobility or motion.

DHS 107.18(2)(d) (d) Onset and termination of spell of illness. The spell of illness begins with the first day of treatment or evaluation following the onset of the new disease, injury or medical condition or increased severity of a pre-existing medical condition and ends when the recipient improves so that treatment by a speech and language pathologist for the condition causing the spell of illness is no longer required, or after 35 treatment days, whichever comes first.