S.D. Admin. R. 67:16:02:03.01

Current through Register Vol. 51, page 54, October 28, 2024

Section 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 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.

S.D. Admin. R. 67:16:02:03.01

9 SDR 164, effective 6/30/1983; 17 SDR 200, effective 7/1/1991; 18 SDR 78, effective 11/4/1991; 19 SDR 26, effective 8/23/1992; 19 SDR 165, effective 5/3/1993; 20 SDR 28, effective 8/31/1993; 23 SDR 38, effective 9/26/1996; 34 SDR 68, effective 9/12/2007; 37 SDR 236, effective 6/28/2011; 37 SDR 236, adopted June 8, 2011, effective 7/1/2012; 44 SDR 94, effective 12/4/2017

General Authority: SDCL 28-6-1.

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