<html xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office" xmlns:w="urn:schemas-microsoft-com:office:word" xmlns="http://www.w3.org/TR/REC-html40"> <head> <title>Rule 67:16:03:06.11 Basis of reimbursement -- Outpatient surgical procedures covered under subdivision 67:16:03:03(10).</title> <META NAME="Keywords" Content="Administrative Rules 67:16:03:06.11"> <META NAME="Description" Content="Administrative Rules 67:16:03:06.11 Basis of reimbursement -- Outpatient surgical procedures covered under subdivision 67:16:03:03(10)."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=ProgId content=Word.Document> <meta name=Generator content="Microsoft Word 10"> <meta name=Originator content="Microsoft Word 10"> <link rel=File-List href="6716030000611d_files/filelist.xml"> <!--[if gte mso 9]><xml> <o:DocumentProperties> <o:Author>lrpr14533</o:Author> <o:LastAuthor>lrpr14296</o:LastAuthor> <o:Revision>2</o:Revision> <o:TotalTime>0</o:TotalTime> <o:Created>2008-09-12T13:22:00Z</o:Created> <o:LastSaved>2008-09-12T13:22:00Z</o:LastSaved> <o:Pages>2</o:Pages> <o:Words>363</o:Words> <o:Characters>2073</o:Characters> <o:Company>State of South Dakota</o:Company> <o:Lines>17</o:Lines> <o:Paragraphs>4</o:Paragraphs> <o:CharactersWithSpaces>2432</o:CharactersWithSpaces> <o:Version>10.6839</o:Version> </o:DocumentProperties> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:SpellingState>Clean</w:SpellingState> <w:GrammarState>Clean</w:GrammarState> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--> <style> <!-- /* Font Definitions */ @font-face {font-family:Times; 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font-family:"Times New Roman";} </style> <![endif]--><!--[if gte mso 9]><xml> <o:shapedefaults v:ext="edit" spidmax="1026"/> </xml><![endif]--><!--[if gte mso 9]><xml> <o:shapelayout v:ext="edit"> <o:idmap v:ext="edit" data="1"/> </o:shapelayout></xml><![endif]--> </head> <body lang=EN-US style='tab-interval:.5in'> <div class=Section1> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>67:16:03:06.11.<span class=GramE>&nbsp;&nbsp;Basis</span> of reimbursement -- Outpatient surgical procedures covered under subdivision 67:16:03:03(10).</b> Reimbursement for an outpatient surgical procedure covered under subdivision 67:16:03:03(10) is calculated according to the following:<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(1)&nbsp;&nbsp;If the procedure is not covered under &#167;&nbsp;67:16:28:04, payment is calculated according to &#167;&nbsp;67:16:03:06.01;<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(2)&nbsp;&nbsp;If the procedure is covered under &#167;&nbsp;67:16:28:04 and falls into a Payment Group of 1, 2, 3, or 4, multiply the payment amount assigned to the payment group under &#167;&nbsp;67:16:03:06.14 by one of the following, as applicable;<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(a)&nbsp;&nbsp;If the hospital is classified as Class I, 1.25;<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(b)&nbsp;&nbsp;If the hospital is classified as Class II, 1.10; or<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(c)&nbsp;&nbsp;If the hospital is classified as Class III, 1.00;<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(3)&nbsp;&nbsp;If the procedure is covered under &#167;&nbsp;67:16:28:04 and falls into a Payment Group of 5, payment is calculated according to &#167;&nbsp;67:16:03:06.01;<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(4)&nbsp;&nbsp;If more than one procedure is performed in a single operating session or on the same day and all of the procedures are covered under &#167;&nbsp;67:16:28:04 and have a payment group of 1, 2, 3, or 4, the procedure with the highest reimbursement rate is payable at 100 percent of the rate calculated according to subdivision (2) of this section and each additional procedure is reimbursed at 50 percent of the rate calculated according to subdivision (2) of this section;<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(5)&nbsp;&nbsp;If more than one procedure is performed in a single operating session or on the same day and any one of the procedures is not covered under &#167;&nbsp;67:16:28:04 and have a payment group of 1, 2, 3, or 4, reimbursement is determined according to &#167;&nbsp;67:16:03:06.01. However, if the procedure not covered under &#167;&nbsp;67:16:28:04 is 10040, 16000, 31725, 36000, 36400, 36405, 36406, 36410, 36415, 36600, 46900, 51000, 53670, 53675, 57150, 58300, 58301, or 69090, reimbursement is determined according to subdivision (2) of this rule and no additional reimbursement is allowed for the procedure not listed; and<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(6)&nbsp;&nbsp;If the procedure meets the definition of an emergency as defined in &#167;&nbsp;67:16:03:01 and the claim is coded as such, the rate of reimbursement is determined according to &#167;&nbsp;67:16:03:06.01.<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>Source:</b> 23 SDR 232, effective July 10, 1997; 35 SDR 49, effective September 10, 2008.<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A><o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A><o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>Cross-Reference:</b> Classification of hospitals providing certain outpatient surgical procedures, &#167;&nbsp;67:16:03:06.10.<o:p></o:p></span></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><span style='font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> </div> </body> </html>