This guide provides a comprehensive overview of the Personal Care Screening Tool (PCST) instructions and recent updates to the Personal Care Worker (PCW) services request process for Wisconsin Medicaid, effective January 1, 2025. Staying informed about these changes ensures timely authorization and minimizes delays in care for your patients.
Key Changes to the PCW Request Process
Several significant changes have been implemented to streamline the PCW request process:
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Elimination of Temporary Authorization: Four-week temporary authorizations are no longer granted before receiving the Personal Needs Assessment (PNA). All required documentation, including the PNA and medical records, must be submitted with the initial authorization request. This applies to both new requests and renewals/change in condition requests. This change emphasizes the importance of complete documentation from the outset.
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Comprehensive Clinical Documentation: Updated and detailed clinical documentation is now required from the ordering provider who has personally examined and evaluated the member within three months of the PCW service request. This documentation should clearly demonstrate the medical necessity for PCW services.
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Physical & Occupational Therapy Requirements: If the assessment suggests the member might benefit from physical or occupational therapy (PT/OT), the clinical documentation must include at least six weeks of therapy notes before services can be approved. This ensures that all other potential avenues for improvement have been explored.
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Durable Medical Equipment (DME) Mandate: If applicable, Durable Medical Equipment (DME) must be present during the PNA, following the guidelines in the Personal Care Screening Tool (PCST) instructions provided by the Wisconsin Department of Health Services (DHS). This ensures the assessment accurately reflects the member’s needs with appropriate assistive devices. You can find specific language regarding DME and therapy in the “Assistive Devices” section on page 2 of the PCST document.
Understanding Personal Care Screening Tool (PCST) Instructions
The PCST is a crucial document in the PCW request process. It guides the assessment of the member’s functional abilities and helps determine the need for PCW services. Refer to the updated PCST instructions on the DHS website for detailed guidance.
Requirements for New and Renewal Referrals
New Referral Requirements:
New referrals necessitate a completed PCST, including an updated PNA. The following documentation is required:
- Outpatient Medicaid Prior Authorization Form
- Home Health Certification and Plan of Care signed by a physician (valid for 60 days)
- Signed physician’s order for PCW services (if not included in the 485 CMS POC form)
- Wisconsin Medicaid PCST completed by a supervisory Registered Nurse (RN)
- Pertinent physician’s notes from the last three months detailing the medical necessity for PCW services, including:
- Documentation of deficits, weaknesses, or physical limitations requiring PCW services
- Status of the deficit (fixed or temporary, potential for improvement with therapy)
- PT/OT evaluation (unless documented that the deficit cannot be improved with therapy)
- Anticipated duration of the deficit
- Potential for improvement with therapy or DME
- At least six weeks of therapy notes, utilizing DME if applicable
- Documentation confirming the presence of DME during the assessment, if applicable
- Documentation of travel time, if applicable
Renewal Requirements:
Renewals for authorizations (up to six months) or requests due to a change in the member’s condition require an updated PNA and the following documentation:
- Outpatient Medicaid Prior Authorization Form
- Home Health Certification and Plan of Care signed by a physician (valid for 60 days)
- Signed physician’s order for PCW services (if not included in the 485 CMS POC form)
- Wisconsin Medicaid PCST completed by a supervisory RN
- Pertinent physician’s notes from the last six months detailing the medical necessity for PCW services, including:
- Documentation of deficits, weaknesses, or physical limitations requiring PCW services
- Status of the deficit (fixed or temporary, potential for improvement with therapy)
- Recent PT/OT notes, if applicable
- Documentation confirming the presence of DME during the assessment, if applicable
- Documentation of travel time, if applicable
- Four weeks of recent PCW notes.
Conclusion
Understanding and adhering to the updated PCST instructions and PCW service request process ensures timely authorization and facilitates the delivery of essential care to Wisconsin Medicaid members. Familiarize yourself with these requirements to minimize processing delays and provide optimal care. For further assistance, contact your Provider Relations representative or the Provider Inquiry Line at 1-800-222-9831.
