<html> <head> <title>Rule 67:16:03:06.18 Basis of Reimbursement -- OPPS.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:03:06.18"> <META NAME="Description" Content="Administrative Rules 67:16:03:06.18 Basis of Reimbursement -- OPPS."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 15 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4;} @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; line-height:115%; font-size:11.0pt; font-family:"Calibri",sans-serif; color:black;} a:link, span.MsoHyperlink {color:blue; text-decoration:underline;} a:visited, span.MsoHyperlinkFollowed {color:#954F72; text-decoration:underline;} .MsoChpDefault {font-family:"Calibri",sans-serif; color:black;} .MsoPapDefault {margin-bottom:10.0pt; line-height:115%;} @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US link=blue vlink="#954F72"> <div class=WordSection1> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>67</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>:</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>16</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>:</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>03</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>:</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>06.18</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>.&nbsp;&nbsp;B</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>a</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>sis of Reimbursement -- OPPS.</span></b><span style='font-size:12.0pt;font-family: "Times New Roman",serif'> Medicare prospective payment</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>system hospitals shall be paid using the Department's OPPS. Under OPPS, services are</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>reimbursed using ambulatory payment classifications. The Department shall establish a</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>conversion factor and discount factor specific to each hospital. The hospital specific conversion</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>factor and discount factors are published on the Department's fee schedule.</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>Outpatient prospective payments may not include items and services for which payment</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>may be made under other provisions of this article, such as physician services, certified</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>registered nurse anesthetist services, prosthetic devices, ambulance services, orthotic devices and</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>durable medical equipment for use in the patient's home, unless the items and services are</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>specifically included in the exception code list on the Department's fee schedule website.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>43</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> SDR </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>80</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>, effective </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>December 5, 2016</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1(2)</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1.1">28-6-1.1.</A></span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1(2)</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1.1">28-6-1.1.</A></span></p> <p class=MsoNormal><span style='font-size:12.0pt;line-height:115%;font-family: "Times New Roman",serif'>&nbsp;</span></p> </div> </body> </html>