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Alert! This chapter may be affected by an emergency rule:
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).
(4)Other limitations.
(a) An x-ray or set of x-rays, such as anterior-posterior and lateral, is a covered service only for an initial visit if the x-ray is performed either in the course of diagnosing a spinal subluxation or in the course of verifying symptoms of other medical conditions beyond the scope of chiropractic.
(b) A diagnostic urinalysis is a covered service only for an initial office visit when related to the diagnosis of a spinal subluxation, or when verifying a symptomatic condition beyond the scope of chiropractic.
(c) The billing for an initial office visit shall clearly describe all procedures performed to ensure accurate reimbursement.
(5)Non-covered services. Consultations between providers regarding a diagnosis or treatment are not covered services.
Note: For more information on non-covered services, see s. DHS 107.03.
History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (2) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 107.16Physical therapy.
(1)Covered services.
(a) General. Covered physical therapy services are those medically necessary modalities, procedures and evaluations enumerated in pars. (b) to (d), when prescribed by a physician and performed by a qualified physical therapist (PT) or a certified physical therapy assistant under the supervision of a physical therapist pursuant to s. PT 5.01. Specific services performed by a physical therapy aide under par. (e) are covered when provided in accordance with supervision requirements under par. (e) 3.
(b) Evaluations. Covered evaluations, the results of which shall be set out in a written report to accompany the test chart or form in the recipient’s medical record, are the following:
1. Stress test;
2. Orthotic check-out;
3. Prosthetic check-out;
4. Functional evaluation;
5. Manual muscle test;
6. Isokinetic evaluation;
7. Range-of-motion measure;
8. Length measurement;
9. Electrical testing:
a. Nerve conduction velocity;
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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.