Wisconsin Legislature: DHS 107.16(1)(b)6.

DHS 107.15(3)(a)(a) Requirement.

DHS 107.15(3)(a)1.1. 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.

DHS 107.15(3)(a)2.2. 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.

DHS 107.15(3)(b)(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:

DHS 107.15(3)(b)1.1. An acute onset of a new spinal subluxation;

DHS 107.15(3)(b)2.2. An acute onset of an aggravation of pre-existing spinal subluxation by injury; or

DHS 107.15(3)(b)3.3. An acute onset of a change in pre-existing spinal subluxation based on objective findings.

DHS 107.15(3)(c)(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.

DHS 107.15(3)(d)(d) Documentation. The chiropractor shall document the spell of illness in the patient plan of care.

DHS 107.15(3)(e)(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.

DHS 107.15(3)(f)(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.

DHS 107.15(3)(g)(g) Department expertise. The department may have on its staff qualified chiropractors to develop prior authorization criteria and perform other consultative activities.

DHS 107.15 NoteNote: For more information on prior authorization, see s. DHS 107.02 (3).

DHS 107.15(4)(4) Other limitations.

DHS 107.15(4)(a)(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.

DHS 107.15(4)(b)(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.

DHS 107.15(4)(c)(c) The billing for an initial office visit shall clearly describe all procedures performed to ensure accurate reimbursement.

DHS 107.15(5)(5) Non-covered services. Consultations between providers regarding a diagnosis or treatment are not covered services.

DHS 107.15 NoteNote: For more information on non-covered services, see s. DHS 107.03.

DHS 107.15 HistoryHistory: 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 107.16DHS 107.16 Physical therapy.

DHS 107.16(1)(1) Covered services.

DHS 107.16(1)(a)(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.

DHS 107.16(1)(b)(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:

DHS 107.16(1)(b)1.1. Stress test;

DHS 107.16(1)(b)2.2. Orthotic check-out;

DHS 107.16(1)(b)3.3. Prosthetic check-out;

DHS 107.16(1)(b)4.4. Functional evaluation;

DHS 107.16(1)(b)5.5. Manual muscle test;

DHS 107.16(1)(b)6.6. Isokinetic evaluation;

DHS 107.16(1)(b)7.7. Range-of-motion measure;

DHS 107.16(1)(b)8.8. Length measurement;

DHS 107.16(1)(b)9.9. Electrical testing:

DHS 107.16(1)(b)9.a.a. Nerve conduction velocity;

DHS 107.16(1)(b)9.b.b. Strength duration curve — chronaxie;

DHS 107.16(1)(b)9.c.c. Reaction of degeneration;