August 2013

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Provider Information

Got a License?
Do you or the facility you work for have a license in order to provide health care services? If yes, you must update your SD MEDX provider record with us every time you renew your license or get related renewals such as a DEA #. License renewals for South Dakota providers with designations of PA, MD, DO, PT, and OT have already completed their 2013 renewal periods. DDS and most facility licenses expire July 1.

Temporary Providers
Medical students in a residency program qualify to have a license. Providers acting as locum tenens are also required to be licensed. This means that these individuals must have a type 1 servicing NPI enrolled with South Dakota Medicaid and claims must be billed using that NPI. It is not appropriate to use of the NPI belonging to the resident's supervising physician or to use the full-time provider's NPI with a Q6 modifier on claims in lieu of enrolling the NPI for the person who saw the patient.

Inpatient Hospitalization Notification

The Inpatient hospitalization form for stays over six days will be moved to an online fillable form and submission process in August 2013. This new link will be located on the Medical Services website

Each South Dakota hospital, as well as those within a 50 mile radius of the South Dakota border, will receive correspondence with instructions to log in and utilize this form. This new process will allow hospitals to track submissions with verification numbers. Providers will also use the verification numbers to update forms with discharge information.

Employee Spotlight

Nicki Bartel is the Nursing Manager and Early Periodic Screening Diagnosis and Treatment (EPSDT) coordinator for the Division of Medical Services. In addition to ensuring children receive access to EPSDT services, she works with the nursing staff to advise on prior authorization determinations and the management of lengthy inpatient stays. She is also the lead contact for the Children's Health Insurance Program (CHIP) and coordinates the required reporting to the Centers for Medicare and Medicaid and other organizations. Nicki has worked in her current position for a year and a half, and has been with the Division of Medical Services for over 7 years.

Nicki graduated from Dakota State University with a degree in Health Information Management and maintains her RHIT certification. After working several years in that field she attended the University of South Dakota to become a Registered Nurse.

New Employees

Danette Jacob

Danette Jacob is the Claims Processing Supervisor for South Dakota Medicaid. She oversees the claims processing and encoding. Danette came to us with previous experience as a medical biller in private industry. She has worked in the medical field since 1997 in both claims processing and customer service in South Dakota and Nebraska.

Mathias Dosch

As a summer intern for the Division of Medical Services, Mathias Dosch is assisting with a wide variety of projects, including the implementation of the Health Home Initiative. Mathias grew up in Pierre, South Dakota and graduated from TF Riggs High School. Mathias received his BS in Psychology and Sociology from Black Hills State University in Spearfish in May 2013.

Important Contact Numbers

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Telephone Service Unit for Claim Inquires:

In State Providers: 1-800-452-7691

Out of State Providers: 605-945-5006

Provider Response (Enrollment and Update Information): 1-866-718-0084

Medical Assistance for Recipients: 1-800-597-1603

Dental Claim and Eligibility Inquiries: 1-800-627-3961

Managed Care Updates: 605-773-3495

Pharmacy Prior Authorization: 1-866-705-5391

Medical & Psychiatric Prior Authorization:

Recipient Premium Assistance: 1-888-828-0059

Welfare Fraud Hotline: 1-800-765-7867

Medicare: 1-800-633-4227

Division of Medical Services Fax: 605-773-5246

Provider Enrollment Fax: 605-773-8520

FY2014 Fee Schedules

Medicaid providers will see reimbursement rate changes, per appropriated budget, beginning with services provided after July 1, 2013. FY2014 Fee schedules are available at:

Please take a moment to review the new fee schedules. If you have questions, please contact us at 605-773-3495.

Enhanced Primary Care Payments

The Patient Protection and Affordable Care Act (PPACA) mandates states to reimburse eligible providers for certain primary care services at an enhanced rate for services provided between 1/1/2013 and 12/31/2014. Per federal guidance, physicians must self-attest in order to receive the enhanced payment. The Enhanced Primary Care Payment fee schedule is posted with the Physicians Services fee schedules. More information about this payment can be found at

The enhanced payment rates were implemented as part of ongoing claims processing in the 6/27/2013 payroll.

First Health Home Recipients Notified of Eligibility in Late June

After more than a year of hard work and stakeholder input, the Department of Social Services officially kicked-off Health Homes by notifying recipients of their eligibility in late June.

The Health Home initiative is designed to help lower the cost of services for Medicaid recipients with chronic conditions while simultaneously improving the health outcomes for the eligible population. Health Homes have been developed in South Dakota at the recommendation of the Governor's Medicaid Solutions Workgroup with the invaluable and ongoing input of the Health Homes Workgroup.

The Department of Social Services (DSS) opened up the provider application phase of the project in April and was pleased to have close to 100 applications from clinics, community health centers, Indian Health Service units, and Community Mental Health Centers across the state. DSS is working with each Health Home location to ensure they receive an orientation to help them prepare to provide the Health Home core services.

Information on Health Homes can be found on the DSS website at or questions about Health Homes can be addressed to Kathi Mueller at (605) 773-3495 or

South Dakota Electronic Health Record (EHR) Incentive Payment Program

Established by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the Medicaid EHR Incentive Payment Program provides incentive payments for eligible providers for the adoption and meaningful use of certified Electronic Health Records (EHRs).

Phase one allows eligible hospitals including acute care and children's hospitals and eligible providers to register and attest for the South Dakota program. Eligible hospitals must register and attest before December 31, 2013 in order to receive a payment for 2013. Physicians, certified nurse midwives, dentists, nurse practitioners, and some physician assistants are eligible professionals who have until March 1, 2014 to register and attest to receive their 2013 incentive payment.

The program makes a series of payments to eligible providers based on the providers meeting and demonstrating the program objectives. Many South Dakota providers are receiving their second payments by demonstrating meaningful use of their E.H.R systems.

If you wish to contact the South Dakota Medicaid EHR Incentive Payment Program or if you have any other questions, please call 605-773-3495 or email Sign up for the listserv and learn more about the program by visiting the EHR Incentive Payment website at

For assistance completing the process of enrolling in or attesting for the E.H.R. Payment Program, contact the regional extension center, HealthPOINT, an EHR resource and support center for South Dakota at (605) 256-5555 or

Primary Care Provider Status Changes

Through a recent quality assurance review the Managed Care program identified a number of providers who had status changes and did not inform South Dakota Medicaid. Failure to notify South Dakota Medicaid about provider status changes may result in the need for Medicaid to request a return of payments previously processed through Medicaid.

The South Dakota Medicaid Managed Care program requests a 30-day notice for any provider leaving a practice for any reason, retirement, or transfer to another clinic location. Additionally clinics should provide immediate notice of an unexpected departure, including death.

Please issue the notice in writing to the Managed Care Program located at 700 Governors Drive, Pierre, South Dakota. The notice should include the provider's name, NPI numbers, and last day of work and should also specify how the provider's caseload is to be re-assigned. Providers have a choice of two options for caseload re-assignment:

1. Transfer the provider's caseload to another provider in the same facility; or
2. Close the provider. When a provider is closed, Managed Care issues a letter to each Medicaid recipient patient of that provider requesting the recipient choose a new primary care provider.

You can review the PCP list at to make sure the right physicians are on the list and that we have the correct phone number listed. Please contact the Managed Care Program at 605-773-3495, if you need to report a recent provider status change or with any other questions.

Chiropractic Services Billing Requirements Administrative Rule Change

South Dakota Medicaid has revised the Administrative Rules of South Dakota (ARSD) relating to the billing requirements for chiropractic services in ARSD 67:16:09:05. The change allows chiropractic providers to submit a claim for procedure code 99211 no more than once in any twelve month period. The previous version of the rule restricted chiropractic providers to billing procedure code 99211 no more than once every three years.

The rule change stipulates that annual claims for the procedure code must show continued medical necessity and progress towards improvement of the condition, negating the possibility of maintenance therapy. The rule change allows for an additional claim for procedure code 99211 to be submitted within the twelve month period for a separate and distinct injury with supporting documentation of medical necessity. The changes to the rule are effective June 24, 2013.

Further information about billing requirements for chiropractic providers can be found in the Professional Services Manual, located on the department's website.

When to use the Modifier 59?

The National Correct Coding Initiative (CCI) has caused some Providers claims to deny for "procedure code denied based on CCI editing. " The appropriate use of the 59 modifier may prevent your claims from denying and needing to be resubmitted.

The CPT Manual defines modifier 59 as: "Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

The National Correct Coding Initiative (NCCI) utilizes certain HCPCS/CPT modifiers to bypass Procedure-to-Procedure (PTP) edits in defined circumstances. Modifier 59 is an important PTP-associated modifier that is often used incorrectly. For the NCCI, its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.

NCCI PTP edits define when two procedure HCPCS/CPT codes may not be reported together except under special circumstances. If an edit allows use of PTP-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or different patient encounters. State Medicaid claim processing systems utilize PTP-associated modifiers to allow payment of both codes of an edit. Modifier 59 and other PTP- associated modifiers should NOT be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any PTP-associated modifier used.

One of the misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe a "different procedure or surgery". The code descriptors of the two codes of a code pair edit usually represent different procedures or surgeries. The edit indicates that the two procedures/surgeries cannot be reported together if performed at the same anatomic site and same patient encounter. The provider cannot use modifier 59 for such an edit based on the two codes being different procedures/surgeries.

However, if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures/surgeries on that date of service.

Use of modifier 59 to indicate different procedures/ surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.

From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes a single anatomic site. Treatment of posterior segment structures in the eye constitute a single anatomic site.


Comments or questions?
Contact Medical Services

South Dakota Department of Social Services

Division of Medical Services
700 Governors Drive
Pierre, SD 57501
Phone 605.773.3495

Fax 605.773.5246

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