CHAPTER 67:16:28
AMBULATORY SURGICAL CENTERS (ASCs)
Section
67:16:28:00 Definitions.
67:16:28:01 Eligible ambulatory surgical centers.
67:16:28:02 Services included in ASC reimbursement.
67:16:28:03 Services not included in ASC reimbursement.
67:16:28:04 Surgical services covered.
67:16:28:05 Rate of payment.
67:16:28:06 Payment for multiple procedures.
67:16:28:07 Repealed.
67:16:28:08 Utilization review.
67:16:28:09 Billing requirements.
67:16:28:10 Claim requirements.
67:16:28:11 Application of other chapters.
Appendix A List of Covered Ambulatory Surgical Procedures, repealed, 35 SDR 49, effective September 10, 2008
67:16:28:00. Definitions. Terms used in this chapter mean:
(1) "Ambulatory surgical center" or "ASC," a facility which operates exclusively for the purposes of providing surgical services to patients not requiring hospitalization.
Source: 16 SDR 234, effective July 2, 1990.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
DEPARTMENT
OF SOCIAL SERVICES
OFFICE
OF MEDICAL SERVICES
LIST
OF COVERED AMBULATORY SURGICAL PROCEDURES
Chapter
67:16:28
APPENDIX
A
SEE:
§ 67:16:28:04
(Repealed)
Source:
16 SDR 234, effective July 2, 1990; 17 SDR 18, effective August 8, 1990; 17 SDR
200, effective July 1, 1991; 18 SDR 163, effective April 6, 1992; 19 SDR 202,
effective July 5, 1993; 23 SDR 113, effective January 12, 1997; 25 SDR 69,
effective November 12, 1998; repealed, 35 SDR 49, effective September 10, 2008.
67:16:28:01. Eligible ambulatory surgical centers. Reimbursement for ambulatory surgical center (ASC) services under this chapter is limited to a facility which is not a hospital and which is an approved ASC provider under Medicare.
Source: 11 SDR 86, effective December 30, 1984; 16 SDR 234, effective July 2, 1990.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-Reference: Eligible facilities, 42 C.F.R. § 416.25(a).
67:16:28:02. Services included in ASC reimbursement. The ASC facility services that are reimbursable under this chapter include services such as the following:
(1) Nursing, technician, and related services;
(2) Use of ASC facilities;
(3) Drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances and equipment directly related to the provision of surgical procedures;
(4) Diagnostic or therapeutic services or items directly related to the provision of surgical procedures;
(5) Administrative and recordkeeping services;
(6) Housekeeping items and supplies; and
(7) Materials for anesthesia.
Source: 11 SDR 86, effective December 30, 1984; 16 SDR 234, effective July 2, 1990.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-Reference: ASC facility services, 42 C.F.R. § 416.61(c).
67:16:28:03. Services not included in ASC reimbursement. ASC facility services reimbursable under this chapter do not include items and services for which payment may be made under other provisions of this article, such as physician services, laboratory services, X ray or diagnostic procedures, prosthetic devices, ambulance services, orthotic devices, and durable medical equipment for use in the patient's home, unless they are specifically included under § 67:16:28:02.
Source: 11 SDR 86, effective December 30, 1984; 16 SDR 234, effective July 2, 1990.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-Reference: ASC facility services not included, 42 C.F.R. § 416.61.
67:16:28:04. Surgical services covered. Surgical procedures covered under this chapter are limited to those procedures contained on the department's fee schedule website.
The procedures and associated rates of payment are subject to review and amendment under the provisions of § 67:16:01:28.
Source: 11 SDR 86, effective December 30, 1984; 16 SDR 234, effective July 2, 1990; 35 SDR 49, effective September 10, 2008; 42 SDR 51, effective October 13, 2015.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:16:28:05. Rate of payment. The rate of payment for the different groups of covered ambulatory surgical center services is contained on the department's fee schedule website.
The rates of payment for the different groups are subject to review and amendment under the provisions of § 67:16:01:28.
Source: 11 SDR 86, effective December 30, 1984; 16 SDR 234, effective July 2, 1990; 17 SDR 200, effective July 1, 1991; 22 SDR 94, effective January 10, 1996; 23 SDR 113, effective January 12, 1997; 35 SDR 49, effective September 10, 2008; 42 SDR 51, effective October 13, 2015.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1, 28-6-1.1.
67:16:28:06. Payment for multiple procedures. If one covered surgical procedure is performed in a single operative session, payment is 100 percent of the established reimbursement rate. If more than one surgical procedure is performed in a single operative session, the procedure with the highest reimbursement rate is covered at 100 percent of the established rate and each additional procedure is covered at 50 percent of the established reimbursement rate.
Source: 11 SDR 86, effective December 30, 1984; 16 SDR 234, effective July 2, 1990.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-Reference: Rate of payment, 42 C.F.R. § 416.120(c).
67:16:28:08. Utilization review. Utilization review for ASC services shall be provided by the following:
(1) Computerized claims processing;
(2) Postpayment monitoring; and
(3) Peer review.
Source: 11 SDR 86, effective December 30, 1984; 16 SDR 234, effective July 2, 1990.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:16:28:10. Claim requirements. A claim for services provided under this chapter must be submitted on a form which 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) The applicable procedure codes as contained in either CMS Common Procedure Coding System (HCPCS) or the Physicians' Current Procedural Terminology (CPT) for services covered under § 67:16:28:04;
(8) The units of service furnished, if more than one; and
(9) The provider's name and medical assistance identification number.
A separate claim form must be used for each recipient.
Source: 17 SDR 4, effective July 16, 1990; 17 SDR 22, effective August 14, 1990; 18 SDR 78, effective November 4, 1991; 19 SDR 26, effective August 23, 1992; 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; 43 SDR 80, effective December 5, 2016.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
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.
67:16:28:11. Application of other chapters. In addition to the rules contained in this chapter, providers and recipients must meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33, 67:16:34, and 67:16:35.
Source: 17 SDR 184, effective June 6, 1991.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
