S.D. Admin. R. 67:16:03:06.11

Current through Register Vol. 50, page 162, June 24, 2024

Section 67:16:03:06.11 - Basis of reimbursement - Outpatient surgical procedures covered under subdivision 67:16:03:03 (10)

Reimbursement for an outpatient surgical procedure covered under subdivision 67:16:03:03(10) is calculated according to the following:

(1) If the procedure is not covered under § 67:16:28:04, payment is calculated according to § 67:16:03:06.01;

(2) If the procedure is covered under § 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 § 67:16:03:06.14 by one of the following, as applicable;

(a) If the hospital is classified as Class I, 1.25;

(b) If the hospital is classified as Class II, 1.10; or

(c) If the hospital is classified as Class III, 1.00;

(3) If the procedure is covered under § 67:16:28:04 and falls into a Payment Group of 5, payment is calculated according to § 67:16:03:06.01;

(4) 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 § 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;

(5) 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 § 67:16:28:04 and have a payment group of 1, 2, 3, or 4, reimbursement is determined according to § 67:16:03:06.01. However, if the procedure not covered under § 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

(6) If the procedure meets the definition of an emergency as defined in § 67:16:03:01 and the claim is coded as such, the rate of reimbursement is determined according to § 67:16:03:06.01.

S.D. Admin. R. 67:16:03:06.11

23 SDR 232, effective 7/10/1997; 35 SDR 49, effective 9/10/2008.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Classification of hospitals providing certain outpatient surgical procedures, § 67:16:03:06.10.