Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.16 - Physical therapy

Current through June 24, 2024
(1) COVERED SERVICES.
(a)
General.
Covered
				physical therapy services are those medically necessary modalities, procedures
				and evaluations enumerated in pars. (b) to (d), when prescribed by a physician
				and performed by a qualified physical therapist (PT) or a certified physical
				therapy assistant under the supervision of a physical therapist pursuant to s.
				PT 5.01. Specific services performed by a physical therapy aide under par. (e)
				are covered when provided in accordance with supervision requirements under
				par. (e) 3.
(b)
Evaluations.
Covered evaluations, the results of which shall
				be set out in a written report to accompany the test chart or form in the
				recipient's medical record, are the following:
1. Stress test;
2. Orthotic check-out;
3. Prosthetic check-out;
4. Functional evaluation;
5. Manual muscle test;
6. Isokinetic evaluation;
7. Range-of-motion measure;
8. Length measurement;
9. Electrical testing:
a. Nerve conduction velocity;
b. Strength duration curve -
				chronaxie;
c. Reaction of
				degeneration;
d. Jolly test (twitch
				tetanus); and
e. "H"
				test;
10. Respiratory
				assessment;
11. Sensory
				evaluation;
12. Cortical
				integration evaluation;
13. Reflex
				testing;
14. Coordination
				evaluation;
15. Posture
				analysis;
16. Gait
				analysis;
17. Crutch
				fitting;
18. Cane
				fitting;
19. Walker
				fitting;
20. Splint
				fitting;
21. Corrective shoe
				fitting or orthopedic shoe fitting;
22. Brace fitting assessment;
23. Chronic-obstructive pulmonary disease
				evaluation;
24. Hand
				evaluation;
25. Skin temperature
				measurement;
26. Oscillometric
				test;
27. Doppler
				peripheral-vascular evaluation;
28.
				Developmental evaluation:
a.
				Millani-Comparetti evaluation;
b.
				Denver developmental;
c.
				Ayres;
d. Gessell;
e. Kephart and Roach;
f. Bazelton scale;
g. Bailey scale; and
h. Lincoln Osteretsky motion development
				scale;
29. Neuro-muscular
				evaluation;
30. Wheelchair fitting
				- evaluation, prescription, modification, adaptation;
31. Jobst measurement;
32. Jobst fitting;
33. Perceptual evaluation;
34. Pulse volume recording;
35. Physical capacities testing;
36. Home evaluation;
37. Garment fitting;
38. Pain; and
39. Arthrokinematic.
(c)
Modalities.
Covered
				modalities are the following:
1.
				Hydrotherapy:
a. Hubbard tank, unsupervised;
				and
b.
				Whirlpool;
2.
				Electrotherapy:
a. Biofeedback; and
b. Electrical stimulation - transcutaneous
				nerve stimulation, medcolator;
3. Exercise therapy:
a. Finger ladder;
b. Overhead pulley;
c. Restorator;
d. Shoulder wheel;
e. Stationary bicycle;
f. Wall weights;
g. Wand exercises;
h. Static stretch;
i. Elgin table;
j. N-k table;
k. Resisted exercise;
l. Progressive resistive exercise;
m. Weighted exercise;
n. Orthotron;
o. Kinetron;
p. Cybex;
q. Skate or powder board;
r. Sling suspension modalities; and
s. Standing table;
4. Mechanical apparatus:
a. Cervical and lumbar traction;
				and
b. Vasoneumatic pressure
				treatment;
5. Thermal
				therapy:
a. Baker;
b. Cryotherapy - ice immersion or cold
				packs;
c. Diathermy;
d. Hot pack - hydrocollator pack;
e. Infra-red;
f. Microwave;
g. Moist air heat; and
h. Paraffin bath.
(d)
Procedures.
Covered procedures are the following:
1.
				Hydrotherapy:
a. Contrast bath;
b. Hubbard tank, supervised;
c. Whirlpool, supervised; and
d. Walking tank;
2. Electrotherapy:
a. Biofeedback;
b. Electrical stimulation,
				supervised;
c. Iontophoresis (ion
				transfer);
d. Transcutaneous nerve
				stimulation (TNS), supervised;
e.
				Electrogalvanic stimulation;
f.
				Hyperstimulation analgesia; and
g.
				Interferential current;
3. Exercise:
a. Peripheral vascular exercises
				(Beurger-Allen);
b. Breathing
				exercises;
c. Cardiac
				rehabilitation - immediate post-discharge from hospital;
d. Cardiac rehabilitation - conditioning
				rehabilitation program;
e. Codman's
				exercise;
f. Coordination
				exercises;
g. Exercise -
				therapeutic (active, passive, active assistive, resistive);
h. Frenkel's exercise;
i. In-water exercises;
j. Mat exercises;
k. Neurodevelopmental exercise;
l. Neuromuscular exercise;
m. Post-natal exercise;
n. Postural exercises;
o. Pre-natal exercises;
p. Range-of-motion exercises;
q. Relaxation exercises;
r. Relaxation techniques;
s. Thoracic outlet exercises;
t. Back exercises;
u. Stretching exercises;
v. Pre-ambulation exercises;
w. Pulmonary rehabilitation program;
				and
x. Stall bar
				exercise;
4. Mechanical
				apparatus:
a. Intermittent positive pressure
				breathing;
b. Tilt or standing
				table;
c. Ultra-sonic
				nebulizer;
d. Ultra-violet;
				and
e. Phonophoresis;
5. Thermal:
a. Cryotherapy - ice massage,
				supervised;
b. Medcosonulator;
				and
c. Ultra-sound;
6. Manual application:
a. Acupressure, also known as
				shiatsu;
b. Adjustment of traction
				apparatus;
c. Application of
				traction apparatus;
d. Manual
				traction;
e. Massage;
f. Mobilization;
g. Perceptual facilitation;
h. Percussion (tapotement),
				vibration;
i. Strapping - taping,
				bandaging;
j. Stretching;
k. Splinting; and
l. Casting;
7. Neuromuscular techniques:
a. Balance training;
b. Muscle reeducation;
c. Neurodevelopmental techniques - PNR, Rood,
				Temple-Fay, Doman-Delacato, Cabot, Bobath;
d. Perceptual training;
e. Sensori-stimulation; and
f. Facilitation techniques;
8. Ambulation training:
a. Gait training with crutch, cane or
				walker;
b. Gait training for level,
				incline or stair climbing; and
c.
				Gait training on parallel bars; and
9. Miscellaneous:
a. Aseptic or sterile procedures;
b. Functional training, also known as
				activities of daily living - self-care training, transfers and wheelchair
				independence;
c. Orthotic
				training;
d. Positioning;
e. Posture training;
f. Preprosthetic training -
				desensitization;
g. Preprosthetic
				training - strengthening;
h.
				Preprosthetic training - wrapping;
i. Prosthetic training;
j. Postural drainage; and
k. Home program.
(e)
Physical therapy aide
				services.
1. Services which are
				reimbursable when performed by a physical therapy aide meeting the requirements
				of subds. 2. and 3. are the following:
a.
				Performing simple activities required to prepare a recipient for treatment,
				assist in the performance of treatment, or assist at the conclusion of
				treatment, such as assisting the recipient to dress or undress, transferring a
				recipient to or from a mat, and applying or removing orthopedic devices;
Note:
Transportation of the recipient to or from
				  the area in which therapy services are provided is not
				  reimbursable.
b. Assembling
				and disassembling equipment and accessories in preparation for treatment or
				after treatment has taken place;
Note:
Examples of activities are adjustment of
				  restorator, N.K. table, cybex, weights and weight boots for the patient, and
				  the filling, cleaning and emptying of whirlpools.
c. Assisting with the use of equipment and
				performing simple modalities once the recipient's program has been established
				and the recipient's response to the equipment or modality is highly
				predictable; and
Note:
Examples of activities are application of
				  hot or cold packs, application of paraffin, assisting recipient with whirlpool,
				  tilt table, weights and pulleys.
d. Providing protective assistance during
				exercise, activities of daily living, and ambulation activities related to the
				development of strength and refinement of activity.
Note:
Examples of activities are improving
				  recipient's gait safety and functional distance technique through repetitious
				  gait training and increasing recipient's strength through the use of such
				  techniques as weights, pulleys, and cane exercises.
2. The physical therapy aide shall be trained
				in a manner appropriate to his or her job duties. The supervising therapist is
				responsible for the training of the aide or for securing documentation that the
				aide has been trained by a physical therapist. The supervising therapist is
				responsible for determining and monitoring the aide's competency to perform
				assigned duties. The supervising therapist shall document in writing the
				modalities or activities for which the aide has received training.
3. The physical therapy aide shall provide
				services under the supervision of a physical therapist under s. PT
				5.02.
4. Physical therapy aides may
				not bill or be reimbursed directly for their services.