Header:
WISCONSIN ADMINISTRATIVE CODE
DEPARTMENT OF HEALTH SERVICES
CHAPTER DHS 107. COVERED SERVICES
Date:
08/31/2009
Document:
DHS 107.113 Respiratory care for ventilator--assisted recipients.
(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.
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