South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:03.02 - Reimbursement for services containing modifier codes

Current through Register Vol. 51, page 10, July 15, 2024
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.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).