67:16:02:01.  Definitions. Terms used in this chapter mean:

          (1)  "Clinical nurse specialist," an individual who is licensed under SDCL 36-9-85 to perform the functions contained in SDCL 36-9-87, or an individual licensed or certified in another state to perform those functions;

          (2)  "Medical and other health services," any of the items or services covered in this chapter under the sections on physician's and other health services;

          (3)  "Nurse anesthetist," an individual who is qualified under SDCL 36-9-30.1 to perform the functions contained in SDCL 36-9-3.1, or an individual licensed or certified in another state to perform those functions;

          (4)  "Nurse midwife," an individual who is qualified under SDCL chapter 36-9A to perform the functions contained in SDCL 36-9A-13, or an individual licensed or certified in another state to perform those functions;

          (5)  "Nurse practitioner," an individual who is qualified under SDCL chapter 36-9A to perform the functions contained in SDCL 36-9A-12, or an individual licensed or certified in another state to perform those functions;

          (6)  "Physician," a person licensed as a physician in accordance with the provisions of SDCL chapter 36-4 and qualified to provide medical and other health services under this chapter, or an individual licensed or certified in another state to perform those functions;

          (7)  "Physician assistant," an individual qualified and certified under the provisions of SDCL chapter 36-4A to perform the functions contained in SDCL 36-4A-26.l, or an individual licensed or certified in another state to perform those functions;

          (8)  "Postoperative management only," performance of postoperative management by one physician or other licensed practitioner after another physician or other licensed practitioner has performed the surgical procedure;

          (9)  "Preoperative management only," performance of preoperative care and evaluation by one physician or other licensed practitioner before another physician or other licensed practitioner performs the surgical procedure;

          (10)  "Procedure codes," identifying numbers used in the submission of claims for medical, surgical, and diagnostic services;

          (11)  "Reduced services," an instance in which a service or procedure is partially reduced or eliminated at the physician or other licensed practitioner's request; and

          (12)  "Unusual services," an instance in which the service provided is greater than that usually required for the procedure.

          Source: SL 1975, ch 16, § 1; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 16 SDR 64, effective October 8, 1989; 16 SDR 234, effective July 2, 1990; 18 SDR 50, effective September 15, 1991; 19 SDR 165, effective May 3, 1993; 24 SDR 86, effective January 1, 1998; 34 SDR 68, effective September 12, 2007; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1).

          Law Implemented: SDCL 28-6-1(1)(2).

          67:16:02:01.01.  Fee schedules for physician services. Fee schedules for services provided under this chapter are available on the department's fee schedule website. When computing the rate of reimbursement for physician services, the department uses the following fee schedules:

          (1)  Nonlaboratory fee schedule; and

          (2)  Laboratory fee schedule.

          The fee schedules are subject to review and amendment by the department. A provider may request that the department review a particular reimbursement rate for possible adjustment or request the inclusion or exclusion of a particular code from the list. When reviewing the requests, the department shall review paid claims information, Medicare fee schedules, national coding lists, and documentation submitted by the provider or the associated medical professional organization to determine whether a change is warranted.

          Source: 34 SDR 68, effective September 12, 2007; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1)(2).

          Law Implemented: SDCL 28-6-1(1)(2), 28-6-1.1.

          67:16:02:03.01.  Reimbursement for multiple surgeries. The department shall apply the provisions of this section and the fee schedules established under the provisions of § 67:16:02:01.01 to calculate the rate of reimbursement if multiple surgical procedures are performed. Payment for multiple surgical procedures performed during the same operating session is limited to the lesser of the provider's usual and customary charge or the amount specified in the following:

          (1)  Full allowable reimbursement for the primary surgical procedure and for a surgical procedure which cannot stand alone but which is performed as a part of a primary surgical procedure. All other procedures, except for bilateral procedures, performed during the same operating session require the use of the modifier 51 and are payable under the provisions of subdivision (3) of this section;

          (2)  For surgical procedures using the modifier 50 (bilateral procedure), 150 percent of the fee specified in the applicable fee schedule or, if no fee is listed, 40 percent of the provider's usual and customary charge;

          (3)  For secondary surgical procedures using the modifier 51 (multiple procedures performed on the same day), 50 percent of the fee specified in the applicable fee schedule or, if no fee is listed, 30 percent of the provider's usual and customary charge; and

          (4)  No reimbursement for surgical procedures that are incidental to the primary procedure, as determined by the department.

          Source: 9 SDR 164, effective June 30, 1983; 17 SDR 200, effective July 1, 1991; 18 SDR 78, effective November 4, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 165, effective May 3, 1993; 20 SDR 28, effective August 31, 1993; 23 SDR 38, effective September 26, 1996; 34 SDR 68, effective September 12, 2007; 37 SDR 236, effective June 28, 2011; 37 SDR 236, adopted June 8, 2011, effective July 1, 2012; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1)(2).

          Law Implemented: SDCL 28-6-1(1)(2).

          67:16:02:03.02.  Reimbursement for services containing modifier codes. Modifier codes which must be used if applicable are listed in § 67:16:02:03.03. When computing the rate of reimbursement, the department uses the fee schedules established under the provisions of § 67:16:02:01.01. Payment for a service listed with a modifier code is limited to the lesser of the provider's usual and customary charge or the payment established according to the following:

          (1)  For a procedure listed in either fee schedule which is reported with the addition of the modifier 22, 125 percent of the established fee. If the procedure is not listed, 40 percent of the provider's usual and customary charge;

          (2)  For a procedure listed in either fee schedule which is reported with the addition of the modifier, 100 percent of the established fee. If the procedure is not listed, 40 percent of the provider's usual and customary charge;

          (3)  For a procedure listed in either fee schedule which is a combination of a professional component and a technical component and which is for the professional component only and is reported with the addition of the modifier, 30 percent of the established fee for the laboratory procedure and 40 percent of the established fee for the nonlaboratory procedure. If the procedure is not listed in either fee schedule, 40 percent of the provider's usual and customary charge;

          (4)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier 47, the rate listed on the department's fee schedule website;

          (5)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier 50, 150 percent of the established fee. If no fee is listed, 40 percent of the provider's usual and customary charge;

          (6)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier 51, 50 percent of the established fee. If no fee is listed, 30 percent of the provider's usual and customary charge;

          (7)  For a procedure listed in either fee schedule which is reported with the addition of the modifier 52, 75 percent of the established fee. If the procedure is not listed in either fee schedule, 40 percent of the provider's usual and customary charge;

          (8)  For a procedure listed in either fee schedule which is reported with the addition of the modifier 53, 50 percent of the established fee. If no fee is listed, 40 percent of the provider's usual and customary charge;

          (9)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier 54, 75 percent of the established fee. If the procedure is not listed, 40 percent of the provider's usual and customary charge;

          (10)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier 55 or 56, 25 percent of the established fee. If the procedure is not listed, 40 percent of the provider's usual and customary charge;

          (11)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier 59, 100 percent of the established fee. If no fee is listed, 30 percent of the provider's usual and customary charge;

          (12)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier 62, 50 percent of the established fee for each surgeon;

          (13)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier 73 or 74, 50 percent of the established fee. If no fee is established, 40 percent of the provider's usual and customary charge;

          (14)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier 76, 77, 78, or 79, 100 percent of the established fee. If no fee is established, 40 percent of the provider's usual and customary charge;

          (15)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier of 80, 81, or 82, 20 percent of the established fee. If the procedure is not listed, 40 percent of the provider's usual and customary charge;

          (16)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier of AA, AD, QK, QX, QY, or QZ the rate listed on the department's fee schedule website. Time must be reported in 15 minute units beginning from the time the physician or other licensed practitioner begins to prepare the patient for induction and ending when the patient is placed under postoperative supervision and the physician or other licensed practitioner is no longer in personal attendance;

          (17)  For a procedure listed in either fee schedule which is reported with the addition of the modifier AS, 20 percent of the reimbursement calculated according to § 67:16:02:15. If the procedures are not listed in either fee schedule, 40 percent of the reimbursement calculated according to § 67:16:02:15;

          (18)  For a procedure listed in the nonlaboratory fee schedule which is reported with the addition of the modifier SL (state supplied vaccine), payment is limited to the injection only; and

          (19)  For a procedure listed in either fee schedule which is reported with the addition of the modifier TC, 70 percent of the established fee for the laboratory procedure and 60 percent of the established fee for the nonlaboratory procedure. If the procedure is not listed in either fee schedule, 40 percent of the provider's usual and customary charge.

          Source: 17 SDR 200, effective July 1, 1991; 19 SDR 165, effective May 3, 1993; 20 SDR 28, effective August 31, 1993; 34 SDR 68, effective September 12, 2007; 35 SDR 49, effective September 10, 2008; 37 SDR 236, effective June 28, 2011; 37 SDR 236, adopted June 8, 2011, effective July 1, 2012; 40 SDR 229, effective June 30, 2014; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1)(2).

          Law Implemented: SDCL 28-6-1(1)(2).

          67:16:02:03.03.  Required modifier codes. A modifier code provides the means by which the reporting provider indicates on the claim form that a service or procedure performed was altered by some specific circumstance but not changed in its definition or code. If applicable, modifier codes must be included on the provider's claim for services. A list of authorized modifier codes is available on the department's modifier website.

          Source: 17 SDR 200, effective July 1, 1991; 23 SDR 38, effective September 26, 1996; transferred from Appendix D, chapter 67:16:02, 34 SDR 68, effective September 12, 2007; 40 SDR 122, effective January 7, 2014; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1)(2).

          Law Implemented: SDCL 28-6-1(1)(2).

          67:16:02:04.  Physician's services covered. Physician's services covered are limited to the following professional services, which must be medically necessary and provided by a physician or other licensed practitioner to a recipient:

          (1)  Medical and surgical services;

          (2)  Services and supplies furnished incidental to the professional services of a physician or other licensed practitioner;

          (3)  Psychiatric services;

          (4)  Drugs and biologicals administered in a physician or other licensed practitioner's office which cannot be self-administered;

          (5)  Routine physical examinations;

          (6)  Routine visits to a nursing facility, a home and community-based service provider, an intermediate care facility for individuals with intellectual disabilities, or a home and community-based waiver service provider;

          (7)  Cosmetic surgery when incidental to prompt repair following an accidental injury or for the improvement of the functioning of a malformed body member;

          (8)  Family planning services;

          (9)  Pap smears;

          (10)  Dialysis treatments;

          (11)  Hysterectomies as authorized under 42 C.F.R. §§ 441.250 to 441.259, inclusive, as amended to April 1, 2017; and

          (12)  Hyperbaric oxygen therapy if the requirements listed on the department's prior authorization website are met.

          Source: SL 1975, ch 16, § 1; 4 SDR 88, effective June 26, 1978; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 11 SDR 26, effective August 21, 1984; 15 SDR 204, effective July 6, 1989; 16 SDR 234, effective July 2, 1990; 17 SDR 200, effective July 1, 1991; 19 SDR 26, effective August 23, 1992; 20 SDR 144, effective March 10, 1994; 40 SDR 122, effective January 8, 2014; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1)(2).

          Law Implemented: SDCL 28-6-1(1)(2).

          Cross-References:

          Home and community-based services, ch 67:54:04.

          HCBS Waiver operated by the Division of Adult Services and Aging, ch 67:44:03.

          Covered services must be medically necessary, § 67:16:01:06.02.

          67:16:02:05.01.  Physical therapy services covered. Physical therapy services which are ordered by a physician or other licensed practitioner through a written prescription and provided by a physical therapist licensed under SDCL chapter 36-10 or by a physical therapist assistant certified under SDCL chapter 36-10 are covered services under this article.

          Any service provided by a physical therapist assistant shall be billed by the supervising physical therapist.

          Source: 7 SDR 109, effective May 31, 1981; 16 SDR 234, effective July 2, 1990; 19 SDR 165, effective May 3, 1993; 34 SDR 68, effective September 12, 2007; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1(1)(2).

          Cross-Reference: School districts, ch 67:16:37.

          67:16:02:05.08.  Requirements for hyperbaric oxygen therapy. Repealed.

          Source: 20 SDR 144, effective March 10, 1994; 34 SDR 68, effective September 12, 2007; 42 SDR 51, effective October 13, 2015.

          67:16:02:05.09.  Prior authorization for hyperbaric oxygen therapy. Repealed.

          Source: 20 SDR 144, effective March 10, 1994; 42 SDR 51, effective October 13, 2015.

          67:16:02:05.10.  Breast reconstruction. Repealed.

          Source: 28 SDR 166, effective June 12, 2002; 42 SDR 51, effective October 13, 2015.

          67:16:02:05.12.  Cochlear implant -- Prior authorization required. Repealed.

          Source: 28 SDR 178, effective July 3, 2002; repealed, 40 SDR 122, effective January 7, 2014.

          67:16:02:05.13.  Hyperbaric oxygen therapy for individual with diabetes. Repealed.

          Source: 34 SDR 68, effective September 12, 2007; 42 SDR 51, effective October 13, 2015.

          67:16:02:05.14.  Hyperbaric oxygen therapy -- Individual with diabetes -- Course of standard wound care. Repealed.

          Source: 34 SDR 68, effective September 12, 2007; 42 SDR 51, effective October 13, 2015.

          67:16:02:05.15.  Occupational therapy. Occupational therapy services are covered services if ordered by a physician or other licensed practitioner through a written prescription and provided by an occupational therapist licensed under SDCL chapter 36-31 or by an occupational therapy assistant licensed under SDCL chapter 36-31.

          Any service provided by an occupational therapy assistant shall be billed by the supervising occupational therapist.

          Source: 34 SDR 68, effective September 12, 2007; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1)(2).

          Law Implemented: SDCL 28-6-1(1)(2).

          Cross-Reference: School districts, ch 67:16:37.

          67:16:02:11.  Cost sharing. Repealed.

          Source: 9 SDR 164, effective June 30, 1983; 10 SDR 79, effective February 1, 1984; 12 SDR 6, effective July 28, 1985; 31 SDR 191, effective June 8, 2005; 42 SDR 51, effective October 13, 2015.

          67:16:02:13.  Audiological and speech pathology services. Payment may be made for audiological testing and speech-language pathology services if provided by a physician, a clinical audiologist licensed under SDCL chapter 36-24, a speech-language pathologist licensed under SDCL chapter 36-37, or a speech-language pathology assistant licensed under SDCL chapter 36-37.

          Covered services are limited to services provided by a physician or by the clinical audiologist, speech-language pathologist, or speech-language pathology assistant if the patient has a written referral from a physician or other licensed practitioner and the services are necessary to diagnose or treat a medical problem.

          Any service provided by a speech-language pathology assistant shall be billed by the supervising speech-language pathologist.

          Source: 13 SDR 8, effective August 3, 1986; 16 SDR 234, effective July 2, 1990; 19 SDR 165, effective May 3, 1993; 23 SDR 38, effective September 26, 1996; 34 SDR 68, effective September 12, 2007; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1)(2).

          Law Implemented: SDCL 28-6-1(1)(2).

          Cross-Reference: School districts, ch 67:16:37.

          NOTE: Information relating to certification as a clinical audiologist or speech pathologist may be obtained from the American Speech and Hearing Association, 10801 Rockville Pike, Rockville, Maryland 20852.

          67:16:02:15.  Reimbursement for services provided by nurse practitioner, clinical nurse specialist, or physician assistant. Except for laboratory services, radiological services, immunizations, and supplies, services provided by a nurse practitioner, a clinical nurse specialist, or a physician assistant are reimbursed at 90 percent of the fee established under this chapter.

          Reimbursement for laboratory services, radiological services, immunizations, and supplies provided by a nurse practitioner, a clinical nurse specialist, or a physician assistant are reimbursed according to § 67:16:02:03.

          Source: 16 SDR 234, effective July 2, 1990; 18 SDR 107, effective December 29, 1991; 19 SDR 26, effective August 23, 1992; 34 SDR 68, effective September 12, 2007; 37 SDR 236, effective June 28, 2011; 37 SDR 236, adopted June 8, 2011, effective July 1, 2012; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1)(2).

          Law Implemented: SDCL 28-6-1(1)(2).

          67:16:02:16.  Billing requirements -- Modifier codes -- Provider identification numbers. A claim submitted under this chapter must be submitted at the provider's usual and customary charge.

          The laboratory that performed the laboratory test shall submit the claim for the test.

          If relevant, the claim shall identify the modifying circumstance of a service or procedure by the addition of the applicable modifier code to the procedure code.

          A claim submitted for multiple surgeries must contain the applicable procedure code for the primary surgical procedure. All other procedures performed during the same operating session must be billed using the applicable procedure code and modifier 51. A bilateral procedure or a surgical procedure which cannot stand alone but which is performed as a part of a primary surgical procedure is not considered a multiple surgical procedure.

          A claim submitted by a clinical nurse specialist, a nurse practitioner, or a physician assistant must contain the nurse practitioner's, the clinical nurse specialist's, or the physician assistant's provider identification number and may not be submitted under the supervising physician's provider identification number.

          A claim submitted for immunizations must contain the applicable procedure code for the administration of the vaccine and an additional procedure code for the vaccine itself. If the vaccine is supplied by the state, the billing code for the vaccine must contain the two-letter modifier of SL.

          Source: 16 SDR 234, effective July 2, 1990; 17 SDR 200, effective July 1, 1991; 1921 SDR 165, effective May 3, 1993; 23 SDR 38, effective September 26, 1996; 34 SDR 68, effective September 12, 2007; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(1)(2).

          Law Implemented: SDCL 28-6-1(1)(2).

          Cross-References:

          Required modifier codes, § 67:16:02:03.03.

          Third-party liability, ch 67:16:26.

          Claims, ch 67:16:35.

          67:16:02:16.01.  Billing requirements -- Implantable contraceptive capsules and obstetrical services. When computing the rate of reimbursement, the department uses the fee schedules established under the provisions of § 67:16:02:01.01. A claim submitted under this chapter for covered implantable contraceptive capsules and obstetrical services must be submitted at the provider's usual and customary charge and is limited to the nonlaboratory procedure codes listed in the applicable fee schedule.

          A claim submitted for insertion or reinsertion, implantable contraceptive capsule may not include the cost of the kit. The kit must be billed separately.

          Providers must use the appropriate CPT code to indicate obstetric care, antepartum care, delivery, and postpartum care. When applicable, providers must bill using the global delivery codes defined on the department's billing guidance website. A provider may not separate claims for antepartum care, delivery services, or postpartum care when using a global delivery code.

          A claim submitted for postpartum care is limited to hospital and office visits in the 60 days following vaginal or cesarean section delivery.

          The guidelines adopted in § 67:16:01:25 apply unless otherwise noted in this chapter.

          Source: 20 SDR 28, effective August 31, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183, effective April 30, 1995; 23 SDR 38, effective September 26, 1996; 34 SDR 68, effective September 12, 2007; 42 SDR 51, effective October 13, 2015; 43 SDR 80, effective December 5, 2016.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:16:02:17.  Claim requirements. A claim for services provided under this chapter must be submitted on a form or in an electronic format that contains the following information:

          (1)  The recipient's full name;

          (2)  The recipient's medical assistance identification number from the recipient's medical assistance identification card;

          (3)  Third-party liability information required under chapter 67:16:26;

          (4)  Date of service;

          (5)  Place of service;

          (6)  The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;

          (7)  Units of service furnished if more than one;

          (8)  The applicable procedure codes from either the Health Care Common Procedure Coding System (HCPCS) or the Current Procedural Terminology (CPT);

          (9)  The applicable diagnosis codes, as adopted in § 67:16:01:26;

          (10)  The provider's name and National Provider Identification (NPI) number;

          (11)  If the provider is a group provider, the National Provider Identification number of the physician or applicable, enrolled provider who provided the care or service;

          (12)  Type of service; and

          (13)  The modifier code listed in § 67:16:02:03.03, as applicable.

          A separate claim must be submitted for each recipient.

          Source: 17 SDR 4, effective July 16, 1990; 17 SDR 22, effective August 14, 1990; 17 SDR 200, effective July 1, 1991; 18 SDR 78, effective November 4, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 128, effective March 11, 1993; 19 SDR 165, effective May 3, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR 183, effective April 30, 1995; 34 SDR 68, effective September 12, 2007; 40 SDR 122, effective January 7, 2014; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017.

          General Authority: SDCL 28-6-1(2)(4).

          Law Implemented: SDCL 28-6-1(2)(4).

          Cross-References:

          Claims, ch 67:16:35.

          Use of CPT, § 67:16:01:25.

          Use of HCPCS, § 67:16:01:27.

          Note: The CMS 1500 form substantially meets the requirements of this rule and its content and appearance are acceptable to the department. These forms are available for direct purchase through the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402.  (202) 783-3238 - pricing desk.

          67:16:02:18.  Certain services exempt from diagnosis code requirements. Repealed.

          Source: 17 SDR 4, effective July 16, 1990; 42 SDR 51, effective October 13, 2015; 43 SDR 80, effective December 5, 2016.