Wisconsin Administrative Code
Department of Health Services
DHS 101-109 - Medical Assistance
Chapter DHS 107 - Covered Services
Section DHS 107.18 - Speech and language pathology services
Universal Citation: WI Admin Code ยง DHS 107.18
Current through February 26, 2024
(1) COVERED SERVICES.
(a) General. Covered speech and
language pathology services are those medically necessary diagnostic,
screening, preventive or corrective speech and language pathology services
prescribed by a physician and provided by a certified speech and language
pathologist or under the direct, immediate on-premises supervision of a
certified speech and language pathologist.
(b) Evaluation procedures. Evaluation or
re-evaluation procedures shall be performed by certified speech and language
pathologists. Tests and measurements that speech and language pathologists may
perform include the following:
1. Expressive
language:
a. Aphasia evaluation (examples of
tests are Eisenson, PICA, Schuell);
b. Articulation evaluation (examples of tests
are Arizona articulation, proficiency scale, Goldman-Fristoe test of
articulation, Templin-Darley screening and diagnostic tests of
articulation);
c. Cognitive
assessment (examples are tests of classification, conservation, Piagetian
concepts);
d. Language concept
evaluation (examples are tests of temporal, spatial, and quantity concepts,
environmental concepts, and the language of direction);
e. Morphological evaluation (examples are the
Miller-Yoder test and the Michigan inventory);
f. Question evaluation - yes-no, is-are,
where, who, why, how and when;
g.
Stuttering evaluation;
h. Syntax
evaluation;
i. Vocabulary
evaluation;
j. Voice
evaluation;
k. Zimmerman pre-school
language scale; and
L. Illinois
test of psycholinguistic abilities;
2. Receptive language:
a. ACLC or assessment of children's language
comprehension;
b. Aphasia
evaluation (examples of tests are Eisenson, PICA, Schuell);
c. Auditory discrimination evaluation
(examples are the Goldman-Fristoe-Woodcock test of auditory discrimination and
the Wepman test of auditory discrimination);
d. Auditory memory (an example is
Spencer-MacGrady memory for sentences test);
e. Auditory processing evaluation;
f. Cognitive assessment (examples are tests
of one-to-one correspondence, and seriation classification
conservation);
g. Language concept
evaluation (an example is the Boehm test of basic concepts);
h. Morphological evaluation (examples are
Bellugi-Klima grammatical comprehension tests, Michigan inventory, Miller-Yoder
test);
i. Question
evaluation;
j. Syntax
evaluation;
k. Visual
discrimination evaluation;
L.
Visual memory evaluation;
m. Visual
sequencing evaluation;
n. Visual
processing evaluation;
o.
Vocabulary evaluation (an example is the Peabody picture vocabulary
test);
p. Zimmerman pre-school
language scale; and
q. Illinois
test of psycholinguistic abilities;
3. Pre-school speech skills:
a. Diadochokinetic rate evaluation;
and
b. Oral peripheral evaluation;
and
4. Hearing-auditory
training:
a. Auditory screening;
b. Informal hearing evaluation;
c. Lip-reading evaluation;
d. Auditory training evaluation;
e. Hearing-aid orientation evaluation;
and
f. Non-verbal
evaluation.
(c) Speech procedure treatments. The
following speech procedure treatments shall be performed by a certified speech
and language pathologist or under the direct, immediate, on-premises
supervision of a certified speech and language pathologist:
1. Expressive language:
a. Articulation;
b. Fluency;
c. Voice;
d. Language structure, including phonology,
morphology, and syntax;
e. Language
content, including range of abstraction in meanings and cognitive skills;
and
f. Language functions,
including verbal, non-verbal and written communication;
2. Receptive language:
a. Auditory processing - attention span,
acuity or perception, recognition, discrimination, memory, sequencing and
comprehension; and
b. Visual
processing - attention span, acuity or perception, recognition, discrimination,
memory, sequencing and comprehension;
3. Pre-speech skills:
a. Oral and peri-oral structure;
b. Vegetative function of the oral motor
skills; and
c. Volitional oral
motor skills; and
4.
Hearing/auditory training:
a. Hearing
screening and referral;
b. Auditory
training;
c. Lip reading;
d. Hearing aid orientation;
and
e. Non-verbal
communication.
(2) SERVICES REQUIRING PRIOR AUTHORIZATION.
(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.
(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.
(c) Conditions justifying spell of illness
designation. The following conditions may justify designation of a new spell of
illness:
1. An acute onset of a new disease,
injury or condition such as:
a. Neuromuscular
dysfunction, including stroke-hemiparesis, multiple sclerosis, Parkinson's
disease and diabetic neuropathy;
b.
Musculoskeletal dysfunction, including fracture, amputation, strains and
sprains, and complications associated with surgical procedures; or
c. Problems and complications associated with
physiologic dysfunction, including severe pain, vascular conditions, and
cardio-pulmonary conditions;
2. An exacerbation of a pre-existing
condition including but not limited to the following, which requires speech
therapy intervention on an intensive basis:
a.
Multiple sclerosis;
b. Rheumatoid
arthritis; or
c. Parkinson's
disease; or
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.
(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.
(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.
(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.
(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.
(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.
(3) OTHER LIMITATIONS.
(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:
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
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.
(b) Restorative
therapy services. Restorative therapy services shall be covered services except
as provided under sub. (4) (b).
(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.
(d) Maintenance therapy services.
Preventive or maintenance therapy services shall be covered services only when
one or more of the following conditions are met:
1. The skills and training of a therapist are
required to execute the entire preventive and maintenance program;
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
3. When, due to the severity or complexity of
the recipient's condition, nursing personnel cannot handle the recipient safely
and effectively.
(e)
Extension of therapy services. Extension of therapy services shall not be
approved in any of the following circumstances:
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;
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;
3. The recipient has achieved independence in
daily activities or can be supervised and assisted by restorative nursing
personnel;
4. The evaluation
indicates that the recipient's abilities are functional for the person's
present way of life;
5. The
recipient shows no motivation, interest, or desire to participate in therapy,
which may be for reasons of an overriding severe emotional
disturbance;
6. Other therapies are
providing sufficient services to meet the recipient's functioning needs;
or
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.
(4) NON-COVERED SERVICES. The following services are not covered services:
(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";
(b) Those services that can be performed by
restorative nursing, as under s.
DHS
132.60(1) (b) to (d); and
(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.
For more information on non-covered services, see s. DHS 107.03.
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