Chapter DHS 107

DHS 107.16(3)(c) (c) Maintenance therapy services. Preventive or maintenance therapy services shall be covered services only when one of the following conditions are met:

DHS 107.16(3)(c)1. 1. The skills and training of a therapist are required to execute the entire preventive and maintenance program;

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)(b) (b) Those services that can be performed by restorative nursing, as under s. DHS 132.60 (1) (b) through (d);

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 DHS 107.17 Occupational therapy.

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;