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 NoteNote: 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.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)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. DHS 107.18(2)(e)(e) Documentation. The speech and language pathologist shall document the spell of illness in the patient plan of care, including measurable evidence that the recipient has incurred a demonstrated functional loss of ability to perform daily living skills. DHS 107.18(2)(f)(f) 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 107.18(2)(g)(g) Other coverage. Treatment days covered by medicare or other third-party insurance shall be included in computing the 35-day per spell of illness total. DHS 107.18(2)(h)(h) Department expertise. The department may have on its staff qualified speech and language pathologists to develop prior authorization criteria and perform other consultative activities. DHS 107.18 NoteNote: For more information on prior authorization, see s. DHS 107.02 (3). DHS 107.18(3)(a)(a) Plan of care for therapy services. Services shall be furnished to a recipient under a plan of care established and periodically reviewed by a physician. The plan shall be reduced to writing before treatment is begun, either by the physician who makes the plan available to the provider or by the provider of therapy when the provider makes a written record of the physician’s oral orders. The plan shall be promptly signed by the ordering physician and incorporated into the provider’s permanent record for the recipient. The plan shall: DHS 107.18(3)(a)1.1. State the type, amount, frequency, and duration of the therapy services that are to be furnished the recipient and shall indicate the diagnosis and anticipated goals. Any changes shall be made in writing and signed by the physician or by the provider of therapy services or physician on the staff of the provider pursuant to the attending physician’s oral orders; and DHS 107.18(3)(a)2.2. Be reviewed by the attending physician, in consultation with the therapist providing services, at whatever intervals the severity of the recipient’s condition requires but at least every 90 days. Each review of the plan shall contain the initials of the physician and the date performed. The plan for the recipient shall be retained in the provider’s file. DHS 107.18(3)(b)(b) Restorative therapy services. Restorative therapy services shall be covered services except as provided under sub. (4) (b). DHS 107.18(3)(c)(c) 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 107.18(3)(d)(d) Maintenance therapy services. Preventive or maintenance therapy services shall be covered services only when one or more of the following conditions are met: DHS 107.18(3)(d)1.1. The skills and training of a therapist are required to execute the entire preventive and maintenance program; DHS 107.18(3)(d)2.2. The specialized knowledge and judgment of a speech 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 re-evaluations required; or DHS 107.18(3)(d)3.3. When, due to the severity or complexity of the recipient’s condition, nursing personnel cannot handle the recipient safely and effectively. DHS 107.18(3)(e)(e) Extension of therapy services. Extension of therapy services shall not be approved in any of the following circumstances: DHS 107.18(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 107.18(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 107.18(3)(e)3.3. The recipient has achieved independence in daily activities or can be supervised and assisted by restorative nursing personnel; DHS 107.18(3)(e)4.4. The evaluation indicates that the recipient’s abilities are functional for the person’s present way of life; DHS 107.18(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 107.18(3)(e)6.6. Other therapies are providing sufficient services to meet the recipient’s functioning needs; or DHS 107.18(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 107.18(4)(4) Non-covered services. The following services are not covered services: DHS 107.18(4)(a)(a) Services which are of questionable therapeutic value in a program of speech and language pathology. For example, charges by speech and language pathology providers for “language development — facial physical,” “voice therapy — facial physical” or “appropriate outlets for reducing stress”; DHS 107.18(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 107.18 NoteNote: For more information on non-covered services, see s. DHS 107.03. DHS 107.18 HistoryHistory: Cr Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (a), (b) (intro.), (c) (intro.) (2) (b), (d), (e), (h) and (4) (a), Register, February 1988, No. 386, eff. 3-1-88; emerg. am. (2) (b), (d), (g) and (3) (c), eff. 7-1-88; am. (2) (b), (d), (g), and (3) (c), 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. DHS 107.19(1)(1) Covered services. Covered audiology services are those medically necessary diagnostic, screening, preventive or corrective audiology services prescribed by a physician and provided by an audiologist certified pursuant to s. DHS 105.31. These services include: DHS 107.19(1)(c)(c) Hearing aid or other assistive listening device performance check; DHS 107.19(2)(a)(a) Services requiring prior authorization. The following covered services require prior authorization from the department: DHS 107.19(2)(b)(b) Conditions for review of requests for prior authorization. Requests for prior authorization of audiological services shall be reviewed only if these requests contain the following information: DHS 107.19(2)(b)5.5. The attending physician’s diagnosis, an indication of the degree of impairment and justification for the requested service; DHS 107.19(2)(b)6.6. An accurate cost estimate if the request is for the rental, purchase or repair of an item; and DHS 107.19(2)(b)7.7. If out-of-state non-emergency service is requested, a justification for obtaining service outside of Wisconsin, including an explanation of why the service cannot be obtained in the state. DHS 107.19 NoteNote: For more information on prior authorization, see s. DHS 107.02 (3). DHS 107.19(3)(a)(a) Plan of care for therapy services. Services shall be furnished to a recipient under a plan of care established and periodically reviewed by a physician. The plan shall be reduced to writing before the treatment is begun, either by the physician who makes the plan available to the provider or by the provider of therapy when the provider makes a written record of the physician’s oral orders. The plan shall be promptly signed by the ordering physician and incorporated into the provider’s permanent record for the recipient. The plan shall: DHS 107.19(3)(a)1.1. State the type, amount, frequency, and duration of the therapy services that are to be furnished the recipient and shall indicate the diagnosis and anticipated goals. Any changes shall be made in writing and signed by the physician or by the provider of therapy services or physician on the staff of the provider pursuant to the attending physician’s oral orders; and DHS 107.19(3)(a)2.2. Be reviewed by the attending physician in consultation with the therapist providing services, at whatever intervals the severity of the recipient’s condition requires but at least every 90 days. Each review of the plan shall contain the initials of the physician and the date performed. The plan for the recipient shall be retained in the provider’s file. DHS 107.19(3)(b)(b) Restorative therapy services. Restorative therapy services shall be covered services. DHS 107.19(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 107.19(3)(c)1.1. The skills and training of an audiologist are required to execute the entire preventive or maintenance program;
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Department of Health Services (DHS)
Chs. DHS 101-109; Medical Assistance
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