• Provider Information
  • Introduction
  • Scope of Services
  • Services Provided by Registered Nurses
    • Introduction
    • Supervision of Delegated Tasks
  • Services Provided by Licensed Practical Nurses
  • Classification of Nursing Services
  • Wisconsin Medicaid Certification Requirements
  • Requirements for Providing Ventilator-Dependent Services
    • Introduction
    • Demonstration Renewals
    • Age-Specific Requirements
  • Changes in Certification
• Rights and Responsibilities
  • Introduction
  • Universal Precautions
  • Unacceptable Practices
  • Fees Prohibited by Wisconsin Medicaid
  • Private Duty Nursing Requirements
  • Emergency and Back-Up Procedures
  • Verifying Recipient Eligibility
    • Introduction
    • Limited Benefit Categories
  • Distribution of Medicaid Information
  • Written Statement of Recipient Rights
  • Contracts with Recipient and/or Family
  • Terminating Service to a Recipient
  • Recipient Responsibilities
    • Arrangements with Nurses in Independent Practice
    • Scheduling Providers
    • Freedom from Liability for Covered Services
• Covered Services and Related Limitations
  • Introduction
  • Private Duty Nursing Benefit
  • Recipient Eligibility for Private Duty Nursing Services
    • Introduction
    • Ventilator-Dependent Recipients
    • Recipients Who Are Not Eligible for Private Duty Nursing Services
  • Hours of Care That Qualify as Private Duty Nursing Services
  • Private Duty Nursing Services Reimbursement Requirements
  • Place of Service for Private Duty Nursing Recipients
  • Providing Disposable Medical Supplies
  • Coordination Services for Ventilator-Dependent Recipients
    • Introduction
    • Documenting Coordination Services
    • Reimbursable Coordination Responsibilities
    • Change in Coordinators
  • Coordination Services for Recipients Not Ventilator-Dependent
    • Introduction
    • Coordination Services Documentation
    • Coordination Responsibilities
    • Change in Coordinators
  • Case Sharing
    • Introduction
    • Provider Responsibility
    • Case Sharing Documentation
  • Reimbursement Not Available
    • Introduction
    • Travel and Record-Keeping Time
• Documentation Requirements
  • Introduction
  • Required Information for Medical Record
    • Introduction
    • Physician Signature
  • Documentation Requirements of Supervising Nurses
  • Availability of Records to Others
    • Introduction
    • Record Maintenance After Termination as Wisconsin Medicaid Provider
• Plan of Care
  • Introduction
  • Plan of Care Documentation Methods
    • Introduction
    • Submitting Another Format for the Recipient's Plan of Care
  • Obtaining Plan of Care Forms
  • Developing the Plan of Care
  • Physician's Orders and Signature
    • Introduction
    • Start of Care
    • Certification Period
    • Verbal Orders
  • Plan of Care Requirements
  • Medical Necessity and the Plan of Care
  • Changes to the Plan of Care
• Prior Authorization
  • Introduction
  • Responsibility for Prior Authorization
  • Services Requiring Prior Authorization
    • Introduction
    • Limits on Authorized Services
  • Requesting Private Duty Nursing Hours
    • Introduction
    • Hours of Private Duty Nursing for Children
    • Requesting Pro Re Nata Hours
    • Flexible Use of Weekly Hours
  • Required Documentation for Prior Authorization Requests
    • Introduction
    • Prior Authorization Request Form
    • Private Duty Nursing Prior Authorization Acknowledgment
    • Prior Authorization Attachments
  • Submitting Prior Authorization Requests
  • Prior Authorization Effective Dates
  • Prior Authorization Responses
  • Prior Authorization Backdating
    • Introduction
    • Initial Requests
    • Extraordinary Circumstances
    • Subsequent Requests Will Not Be Backdated
    • Returned Requests
    • Amendment Requests
    • Denied Requests
  • Amending an Approved or Modified Prior Authorization Request
  • Enddating a Prior Authorization Request
  • Out-of-State Private Duty Nursing
    • Introduction
    • Out-of-State Prior Authorization Request Requirements
    • Procedure for Obtaining Authorization for Out-of-State Travel
• Claims Submission
  • Introduction
  • Claims Submission Options
    • Introduction
    • Paper Claims Submission
  • Follow-Up to Claims Submission
  • Billing Across Midnight
  • Daylight Savings Time
• Codes for Prior Authorization and Claims
  • Introduction
  • Revenue Codes
  • Date of Service
  • Procedure Codes
  • Modifiers
    • Introduction
    • Start-of-Shift Modifiers
    • Professional Status Modifiers
    • Case Coordination Modifier
  • Units of Service
    • Introduction
    • Rounding Guidelines
  • Prior Authorization Number
  • Diagnosis Code
• Appendix
• PDF

 

 

Plan of Care

Plan of Care Requirements

As specified in and supported by HFS 107.12(1)(d), 105.19(8), 107.02(2)(f), and 106.02(9), Wis. Admin. Code, the POC must contain medication and treatment orders and medically necessary hours of care as ordered by a physician, in addition to the following elements:

• Treatment orders.
• Medication orders.
• Measurable and time-specific goals.
• Methods for delivering needed care, and an indication of which other professional disciplines, if any, are responsible for delivering care.
• Provisions for care coordination by an RN when more than one nurse is necessary to staff the recipient’s case.
• A description of functional status, mental status, dietary needs, and allergies.
• A dated physician’s signature signifying that the physician has reviewed the POC.
• Nursing and emergency interventions.
• Parameters for all pro re nata (PRN) orders.
• A plan for medical emergencies.
• A plan to move the recipient to safety in the event of a condition that threatens the recipient’s immediate environment.
• Other items as appropriate to the recipient’s case.

Plans of care for ventilator-dependent recipients must also include the following elements:

• Ventilator settings and parameters.
• Procedures to follow in the event of accidental extubation.

Medically necessary hours of skilled nursing care as ordered by a physician are to include hours that may be claimed by professional providers and hours of care routinely provided by the family and other volunteer caregivers.

In addition to the elements required on the POC by HFS 107.12(1)(d), Wis. Admin. Code, NIP should include a brief clinical history and summary of the recipient’s condition to expedite the PA request. This additional information may decrease the frequency of returned PA requests.

For a sample POC documented on the PA/HCA (fillable PDF,139 KB), providers may refer to Appendix 5 of this handbook.

Next — Plan of Care, Medical Necessity and the Plan of Care
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