Current through February 26, 2024
(1) COVERED
SERVICES. Services, medical supplies and equipment necessary to provide life
support for a recipient who has been hospitalized for at least 30 consecutive
days for his or her respiratory condition and who is dependent on a ventilator
for at least 6 hours per day shall be covered services when these services are
provided to the recipient in the recipient's home. A recipient receiving these
services is one who, if the services were not available in the home, would
require them as an inpatient in a hospital or a skilled nursing facility, has
adequate social support to be treated at home and desires to be cared for at
home, and is one for whom respiratory care can safely be provided in the home.
Respiratory care shall be provided as required under ss.
DHS 105.16
and
105.19 and according to a written
plan of care under sub. (2) signed by the recipient's physician for a recipient
who lives in a residence that is not a hospital or a skilled nursing facility.
Respiratory care includes:
(a) Airway
management, consisting of:
1. Tracheostomy
care: all available types of tracheostomy tubes, stoma care, changing a
tracheostomy tube, and emergency procedures for tracheostomy care including
accidental extubation;
2. Tracheal
suctioning technique; and
3. Airway
humidification;
(b)
Oxygen therapy: operation of oxygen systems and auxiliary oxygen delivery
devices;
(c) Respiratory
assessment, including but not limited to monitoring of breath sounds, patient
color, chest excursion, secretions and vital signs;
(d) Ventilator management, as follows:
1. Operation of positive pressure ventilator
by means of tracheostomy to include, but not limited to, different modes of
ventilation, types of alarms and responding to alarms, troubleshooting
ventilator dysfunction, operation and assembly of ventilator circuit, that is,
the delivery system, and proper cleaning and disinfection of
equipment;
2. Operation of a manual
resuscitator; and
3. Emergency
assessment and management including cardiopulmonary resuscitation
(CPR);
(e) The following
modes of ventilatory support:
1. Positive
pressure ventilation by means of a nasal mask or mouthpiece;
2. Continuous positive airway pressure (CPAP)
by means of a tracheostomy tube or mask;
3. Negative pressure ventilation - iron lung,
chest shell or pulmowrap;
4.
Rocking beds;
5. Pneumobelts;
and
6. Diaphragm pacing;
(f) Operation and interpretation
of monitoring devices:
1. Cardio-respiratory
monitoring;
2. Pulse oximetry;
and
3. Capnography;
(g) Knowledge of and skills in
weaning from the ventilator;
(h)
Adjunctive techniques:
1. Chest physiotherapy;
and
2. Aerosolized medications;
and
(i) Case
coordination activities performed by the registered nurse designated in the
plan of care as case coordinator. These activities include coordination of
health care services provided to the recipient at home and coordination of
these services with any other health or social service providers serving the
recipient.
(2) PLAN OF
CARE. A recipient's written plan of care shall be based on the orders of a
physician, a visit to the recipient's home by the registered nurse and
consultation with the family and other household members. The plan of care
established by a home health agency or independent provider for a recipient to
be discharged from a hospital shall consider the hospital's discharge plan for
the recipient. The written plan of care shall be reviewed, signed and dated by
the recipient's physician and renewed at least every 62 days and whenever the
recipient's condition changes. Telephone orders shall be documented in writing
and signed by the physician within 10 working days. The written physician's
plan of care shall include:
(a) Physician
orders for treatments provided by the necessary disciplines specifying the
amount and frequency of treatment;
(b) Medications, including route, dose and
frequency;
(c) Principal diagnosis,
surgical procedures and other pertinent diagnosis;
(d) Nutritional requirements;
(e) Necessary durable medical equipment and
disposable medical supplies;
(f)
Ventilator settings and parameters;
(g) Procedures to follow in the event of
accidental extubation;
(h)
Identification of back-ups in the event scheduled personnel are unable to
attend the case;
(i) The name of
the registered nurse designated as the recipient's case coordinator;
(j) A plan for medical emergency, to include:
1. Description of back-up personnel
needed;
2. Provision for reliable,
24-hour a day, 7 days a week emergency service for repair and delivery of
equipment; and
3. Specification of
an emergency power source; and
(k) A plan to move the recipient to safety in
the event of fire, flood, tornado warning or other severe weather, or any other
condition which threatens the recipient's immediate environment.
(3) PRIOR AUTHORIZATION.
(a) All services covered under sub. (1) and
all home health services under s.
DHS 107.11
provided to a recipient receiving respiratory care shall be authorized prior to
the time the services are rendered. Prior authorization shall be renewed every
12 calendar months if the respiratory care under this section is still needed.
The prior authorization request shall include the name of the registered nurse
who is responsible for coordination of all care provided under the MA program
for the recipient in his or her home. Independent MA-certified respiratory
therapists or nurses in private practice who are not employees of or contracted
to a home health agency but are certified under s.
DHS 105.19(1)
(b) to provide respiratory care shall include
in the prior authorization request the name and license number of a registered
nurse who will participate, on 24-hour call, in emergency assessment and
management and who will be available to the respiratory therapist for
consultation and assistance.
(4) OTHER LIMITATIONS.
(a) Services under this section shall not be
reimbursed if the recipient is receiving respiratory care from an RN, licensed
practical nurse or respiratory therapist who is providing these services as
part of the rental agreement for a ventilator or other respiratory
equipment.
(b) Respiratory care
provided to a recipient residing in a community-based residential facility
(CBRF) as defined in s.
50.01(1g),
Stats., shall be in accordance with the requirements of ch. DHS 83.
(c) Durable medical equipment and disposable
medical supplies shall be provided in accordance with conditions set out in s.
DHS
107.24.
(d) Respiratory care services provided by a
licensed practical nurse shall be provided under the supervision of a
registered nurse and in accordance with standards of practice set out in s.
N
6.04.
(e)
Case coordination services provided by the designated case coordinator shall be
documented in the clinical record, including the extent and scope of specific
care coordination provided.
(f) In
the event that a recipient receiving services at home who is discharged from
the care of one respiratory care provider and admitted to the care of another
respiratory care provider continues to receive services at home under this
section, the admitting provider shall coordinate services with the discharging
provider to ensure continuity of care. The admitting provider shall establish
the recipient's plan of care as provided under sub. (2) and request prior
authorization under sub. (3).
(g)
Travel, recordkeeping and RN supervision of a licensed practical nurse are not
separately reimbursable services.
(5) NON-COVERED SERVICES. The following
services are not covered services:
(a)
Parenting;
(b) Supervision of the
recipient when supervision is the only service provided;
(c) Services provided without prior
authorization;
(d)
1. Except as provided in subd. 2., services
provided by an individual nurse under this section that, when combined with
services provided to all recipients and other patients under the nurse's care,
exceed either of the following limitations:
a.
A total of 12 hours in a calendar day.
b. A total of 60 hours in a calendar
week.
2. Services may
exceed the limitations in subd. 1. when both of the following conditions are
met:
a. The services are approved by the
department on a case-by-case basis for circumstances that could not reasonably
have been predicted.
b. Failure to
provide skilled nursing services likely would result in serious impairment of
the recipient's health.
(e) Services provided in a setting other than
the recipient's place of residence; and
(f) Services that are not medically
appropriate.
(g)
1. Except as provided in subd. 2., services
provided during any 24-hour period during which the nurse who performs the
services has less than 8 continuous and uninterrupted hours off duty.
2. Services may exceed the limitations in
subd. 1. when both of the following conditions are met:
a. The services are approved by the
department on a case-by-case basis for circumstances that could not reasonably
have been predicted.
b. Failure to
provide skilled nursing services likely would result in serious impairment of
the recipient's health.