Materiales y recursos didácticos

Authorization

The following PT, OT, and SLP services require PA starting with the first day of treatment:

• Aural rehabilitation following cochlear implants.

• Cotreatment.

• Dual treatment.

• HealthCheck “Other Services.”

• Services identified by unlisted procedure codes.

• Treatment of decubitus ulcers.

• Treatment for conditions resulting from mental retardation.

Cotreatment

Cotreatment (interdisciplinary treatment) always requires PA. Cotreatment is simultaneous treatment by two providers of different therapy disciplines during the same time period. Cotreatment may be authorized when the treatment approach is medically necessary to optimize the recipient’s benefit from therapy.

Each of the providers involved in cotreatment is required to complete a separate PA request;

the requests must be submitted at the same time. Providers may either mail the PA requests in the same envelope or fax them at the same time. The Prior Authorization

Request Forms (PA/RFs), HCF 11018, may be submitted via the Web if both PA requests are mailed together or faxed at the same time.

Each provider’s PA request for cotreatment must include the following:

• A specific request for cotreatment.

• Documentation verifying the following:

✓ Individual treatment from a single PT, OT, or SLP provider does not provide maximum benefit to the recipient.

✓ Services of two different therapy disciplines, simultaneously performed, are required to treat the recipient.

• Identification of the other provider and therapy discipline.

When cotreatment is approved, “cotreatment is approved” will be written on the bottom of the PA request.

If cotreatment is approved, two providers of different therapy disciplines can be reimbursed by Wisconsin Medicaid for the same time period. For example, if a recipient is treated by an OT provider and an SLP provider from 1:00 to 2:00, both providers could receive Medicaid

If cotreatment

ARCHIVAL USE ONLY

Refer to the Online Handbook for current policy

29

Ext., Maintenance, Svcs.That Always Req. PA

T

reimbursement for one hour. However, if cotreatment is not approved, both the OT provider and the SLP provider would not receive reimbursement for one hour. Instead, each provider could receive reimbursement for 30 minutes.

Dual Treatment

Dual treatment (intradisciplinary treatment) always requires PA. Dual treatment is treatment by two or more providers of the same therapy discipline from different agencies or organizations. Each of the

providers involved in dual treatment is required to complete a separate PA request; the requests must be submitted at the same time.

Providers may either mail the PA requests in the same envelope or fax them at the same time. The PA/RFs may be submitted via the Web if both PA requests are mailed together or faxed at the same time.

Each provider’s PA request for dual treatment must include the following:

• A specific request for dual treatment.

• Identification of the other provider.

• Procedures for coordination of the treatment plans.

• Specific days of the week each provider will provide services.

• The specific and unique contribution of each PT, OT, or SLP provider.

Unlisted Procedure Codes

Services identified by unlisted procedure codes always require PA. Unlisted procedure codes include 97039 for PT services, 97139 for PT and OT services, and 92700 for SLP services.

A PA request with one of these procedure

codes should include an explanation of why no other procedure code accurately reflects the service being requested.

Decubitus Ulcers

Treatment of decubitus ulcers using electrical stimulation always requires PA. When requesting PA for electrical stimulation of decubitus ulcers, the service should be requested as a manual electrical stimulation procedure. Wisconsin Medicaid reimburses only for the face-to-face time that the PT provider is in attendance.

A PA request for electrical stimulation of decubitus ulcers must include documentation of the following:

• The character, size, etc., of the pressure sore.

• The need for additional time for dressing changes.

• Weekly measurements.

• Weekly percentage change in size or healing.

Prior authorization for continuing electrical stimulation treatment is considered only when there has been interval formation of granulation tissue or a 25 percent reduction in area has occurred within 45 treatment days. When this rapid improvement has not occurred within 45 days, a PA request for continuing electrical stimulation treatment must include

documentation of nursing protocols, positioning recommendations, and dietary

ARCHIVAL USE ONLY

Refer to the Online Handbook for current policy

30

ARCHIVAL USE ONLY

Refer to the Online Handbook for current policy

31

RequestingSpell of Illness

R A

Physical therapy (PT), occupational therapy (OT), and speech and language pathology (SLP) providers should submit the Prior Authorization/Spell of Illness Attachment (PA/

SOIA), HCF 11039, when requesting approval for SOI.

The completion instructions and PA/SOIA are located in Appendices 31 and 32 of this handbook for photocopying and may also be downloaded and printed from the Medicaid Web site.

After the initial SOI, any new disease, injury, medical condition, or increased severity of a pre-existing medical condition that requires PT, OT, or SLP services is called a subsequent SOI. A subsequent SOI always requires PA.

When submitting the PA/SOIA, providers are required to provide the appropriate primary International Classification of Diseases, Ninth Revision, Clinical Modification (9-CM) diagnosis code or the appropriate ICD-9-CM surgical procedure code and answer

“yes” or “no” to seven statements about the recipient’s diagnosis or condition. The answers to these statements are used to determine if the SOI request will be approved. If the PA request is approved, Wisconsin Medicaid uses the combination of the ICD-9-CM code and the answers to these statements to assign the maximum allowable treatment days for the SOI.

A PA request for an SOI may be approved if all of the following are true:

• The recipient has incurred a demonstrated functional loss of ability to perform daily living skills within the past six weeks, and there is measurable evidence to support this.

• There is a reasonable expectation that the recipient will return to his or her previous level of function by the end of this SOI or sooner.

• Only one of statements “A” through “F”

from Element 11 of the PA/SOIA would be marked “yes.” If the recipient’s condition could be categorized by more than one of statements “A” through “F,”

providers should choose the statement that best describes the reason for the SOI.

Examples of situations covered in statements “A” through “F” are provided on the back of the PA/SOIA.

Note: Statement “D” does not apply to PT services. Statements “C,” “D,” and “F” do not apply to SLP services.

If these conditions are not met, Wisconsin Medicaid will return the PA request and instruct the provider to use the Prior

Authorization/Therapy Attachment (PA/TA), HCF 11008.

Maximum Allowable