S.D. Admin. R. 67:16:02:03.02

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

Section 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 providers 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 providers 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.

S.D. Admin. R. 67:16:02:03.02

17 SDR 200, effective 7/1/1991; 19 SDR 165, effective 5/3/1993; 20 SDR 28, effective 8/31/1993; 34 SDR 68, effective 9/12/2007; 35 SDR 49, effective 9/10/2008; 37 SDR 236, effective 6/28/2011; 37 SDR 236, adopted June 8, 2011, effective 7/1/2012; 40 SDR 229, effective 6/30/2014; 42 SDR 51, effective 10/13/2015; 44 SDR 94, effective 12/4/2017

General Authority: SDCL 28-6-1.

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