November 2013

Table of Contents

Important Contact Numbers

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Administrative Rules of South Dakota Proposed Revisions

The Medical Services rules package repeals or revises unnecessary or outdated regulations. Revisions clarify existing policies, aligning rule with current practices or terminology. Additionally, this rule package eliminates the homebound requirement for recipients receiving home health services as required by federal rule. The public hearing is scheduled for November 26, 2013 at 11 am at the Department of Social Services at 700 Governors Drive, Pierre, SD. For more information click here.

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Deficit Reduction Act: False Claims Education Attestation

Section 6032 of the Deficit Reduction Act (DRA) of 2005 requires certain entities to educate their employees about false claims recoveries. Per federal law, providers meeting the definition of an "entity” must establish written policies about the False Claims Act and disseminate those policies to all employees, contractors and agents. South Dakota Medicaid is required to provide oversight of this process in accordance with the procedures established in the South Dakota Medicaid State Plan.

To determine if your business or organization meets the definition of an entity, first identify all components of your organization, corporation, partnership or business arrangement. This may include multiple locations, billing NPIs, and FEINs. Then, total all payments from South Dakota Medicaid received in the last federal fiscal year (October 1, 2012 to September 30, 2013). If the total of all payments exceeds $5,000,000 your business meets the definition of an entity and must submit an attestation form by December 31, 2013. If aggregate payments do not exceed $5,000,000 you do not meet the definition of an entity and do not need to attest. Find out more by clicking here:

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Evaluation-and-Management Services Billed with Surgical Procedures

On July 1, 2013 the Medicare National Correct Coding Initiative (NCCI) program added over 300,000 Procedure-to-Procedure (PTP) edits that pair evaluation-and-management (E&M) codes as column 2 codes with all surgical procedure codes (over 5,000 codes). The Medicaid NCCI program implemented these edits on October 1, 2013.

The introduction to the “Surgery” section of the CPT Manual provides a general description of the services that are components of a “surgical package”, including related E&M codes. Medicare has a more detailed definition of a global surgery policy as it relates to E&M codes billed by the surgeon and the Medicare NCCI PTP edits are based on that policy. Because Medicaid NCCI is based on Medicare NCCI, that policy is described in the Medicaid NCCI Policy Manual in the “Evaluation & Management Services” section of the surgery chapters. It is important to note that PTP edits only address codes billed on the same date of service by the same physician. They do not address E&M services rendered prior to the day of surgery or during the global period after the day of surgery.

Medicare divides surgical procedures into two groups:

  • Major surgery - those codes with 090 Global Days in the “Medicare Physician Fee Schedule Relative Value File”
  • Minor surgery - those codes with 000 or 010 Global Days

In brief, the Medicare NCCI policy for same day E&M services states:

  • For major surgical procedures, an E&M service addressing the decision to perform the surgery is payable on the date of surgery. That service should be reported with modifier 57.
  • For minor surgical procedures, an E&M service addressing the decision to perform the surgery is not separately payable on the date of surgery.
  • For all surgical procedures, other E&M services related to the surgical procedure or to post-operative complications that do not require additional trips to the operating room are not separately payable on the day of surgery.
  • For all surgical procedures, other significant and separately identifiable E&M services rendered on the day of surgery are separately payable. They should be reported with modifier 24 or 25, as appropriate.

The 2013 “National Physician Fee Schedule Database / Relative Value File” can be found here.

In the zip file, select document “PPRRVU13_V0215_02132013.xlsx” and refer to “Column O, Global Days”.

As mentioned previously, the PTP edits only address E&M codes billed by the surgeon on the same date of service as the surgery. Also, the PTP edits themselves do not address whether the surgical procedure is a major or minor surgery.

All of the edits will have a Correct Coding Modifier Indicator (CCMI) = 1, which should allow the edit to be bypassed, if a PTP-associated modifier is appended to the E&M code.  The PTP-associated modifiers that are applicable to these edits are:

  • Modifier 24 - Unrelated E&M service during the post-operative period
  • Modifier 25 - Significant, separately reportable E&M service on the same day as the surgery
  • Modifier 57 - E&M service that resulted in the decision to perform a major surgical procedure

For more information, click here.

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Fluoride Varnish Dental Care
Contributed by Delta Dental of South Dakota

Early childhood caries, commonly known as tooth decay, is the most common disease in children and often is accompanied by serious co-morbidities. Although the disease is nearly 100 percent preventable, it affects nearly half of U.S. five-year-olds and is often untreated, particularly in low income pre-school children. Because children are regularly seen by primary care medical personnel, those visits can also be an opportunity for families to receive anticipatory guidance and for the child to receive a preventive oral health service.

South Dakota Medicaid allows non-dental primary care providers (physicians, nurses, physician's assistants and nurse practitioners) to bill for fluoride varnish applications for children under age six. Fluoride varnish (FV) is a topical agent applied to the teeth of patients at risk for tooth decay. The current Medicaid reimbursement rate for FV applications is $18.00 per application. Three applications a year may be billed using code D1206.

For more information about children's oral health, a free one-hour training is available that includes how to do oral health risk assessments, provide anticipatory guidance and apply fluoride varnish. Contact Keri Thompson, dental health coordinator for Delta Dental of South Dakota, at or 1-800-627-3961 with any questions or to schedule a presentation.

Another training option is the Smiles for Life curriculum developed by the Society of Teachers of Family Medicine. This online course allows clinicians to learn more about oral health on their own time and at their own pace. Free CE credit is available. The course can be accessed at

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Health Homes: First Quarter Implementation a Success

The implementation of South Dakota's Health Homes program and the first quarter of Health Home services were completed on September 30, 2013. The Department of Social Services and health home representatives continue to work together to develop the program, and a Health Home Implementation Workgroup has been formed for this purpose.

One of the keys of Health Homes is the collaboration and integration of health care services. During the first quarter of the Health Homes program, partnerships and communication between behavioral health and physical health providers have been developed to help ensure that the individual health home participant's health care is better integrated. There are currently 111 health homes (71 private clinics, 9 CMHC, 11 IHS, 20 FQHC) with 597 designated providers. The number of Health Homes continues to grow, and DSS continues to outreach potential Health Home providers in underserved areas.

As of October 29, 2013 there were 5,875 Medicaid recipients in a Health Home.  Health Homes serve a broader population than the Managed Care program. Any Medicaid recipient, including those who are dually eligible for Medicaid and Medicare, can be eligible for Health Homes as long as they meet the eligibility criteria of having two chronic conditions or one chronic condition and one at-risk condition. All recipients participating in the Health Home program are required to have referrals from their Health Home for those services that require referrals, such as durable medical equipment, ambulatory surgical center services, and therapies.

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Payment Error Rate Measurement (PERM)

South Dakota Medicaid's 2014 PERM cycle has begun. Claims with dates of service between October 1, 2013 and September 30, 2014 are eligible to be pulled for the PERM review. Providers can help the PERM process move smoothly by submitting all requested records and documentation to South Dakota Medicaid in a timely manner upon request. Providers will receive written notification requesting required documentation.

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PCP Enhanced Payment Attestation

Pursuant to the Patient Protection and Affordable Care Act, certain primary care physicians are eligible for enhanced payments for eligible primary care services provided between January 1, 2013 and December 31, 2014.

On October 21, 2013 South Dakota Medicaid distributed a listserv message summarizing the 2014 re-attestation requirement for eligible primary care physicians, physicians' assistants, and advanced practice nurses. More information about the PCP Enhanced Payment, eligibility, and the 2013 and 2014 attestations forms can be found at

Questions about the PCP Enhanced Payment can be directed to 605-773-3495.

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Provider Manuals

Institutional, Long Term Care and Professional provider manuals are a resource provided for providers detailing South Dakota Medicaid claims submission requirements and guidelines. These manuals provide general information, information regarding services, billing instructions for the UB 04 claim form and the CMS 1500 claim form, along with references and links to our Administrative Rules and Regulations. Following the instructions provided in these manuals help eliminate claim denials. The provider manuals can be found at

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Providers Billing Both RHC/FQHC and Non-RHC/Non-FQHC Services

Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) practitioners that intend to bill for non-RHC or non-FQHC services such as professional charges for hospital services as permitted by Medicare must have a separate billing NPI for the non-RHC or non-FQHC services. Claims for these services must be billed on a CMS-1500. Additional details regarding allowable services and billing practices can be found in Chapter 13 of the Medicare Benefit Policy Manual found at and the DSS Professional Billing Manual found at

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Recipient Eligibility Verification Inquiries

Recipients must present their Medical Assistance Program identification card to a Medical Assistance Program provider each time, before obtaining a Medical Assistance Program covered service. Failure to present their Medical Assistance Program identification card is cause for payment denial. Payment for denied services becomes the responsibility of the recipient.

Providers that do not obtain this identification card information from a recipient should attempt to obtain this information from the recipient prior to requesting eligibility information.

With the information available from the recipient eligibility card, providers may use one of several automated methods to obtain eligibility information.

Electronic Verification

The Medicaid Eligibility Verification System (MEVS) gives providers immediate access to a patient's eligibility status for a current or previous date of service. MEVS offers three ways for a provider to access South Dakota's recipient eligibility file. All three options provide prompt response times and printable receipts, and can verify eligibility status for prior dates of service.

  1. Point of Service Terminal - The terminal is a swipe device that works similarly to credit card verification. This device allows recipients to swipe their Medical Assistance Program identification card. This device can be purchased or leased.
  2. PC Software - Using this software, providers may enter the nine digit recipient ID (RID#), and obtain an accurate return of eligibility information.
  3. Secure Web-Based Site - Providers may enter the nine digit recipient ID (RID#) on the secure website to obtain an accurate return of eligibility info.

These services are available through Web MD Emdeon. There is a nominal fee for each verification obtained through Emdeon. For information about the MEVS system, new customers may contact Emdeon at 1-866-369-8805 or at 1-877-469-3263 for existing customers. Providers may also visit Emdeon's website at

Telephone Audio Response Unit

As an alternative to electronic verification, providers may use the SD Medical Assistance telephone audio response unit by calling 1-800-452-7691. Each call takes approximately one minute to complete. This system is limited to current eligibility verification only and five inquiries at a time. This call can be completed through a series of questions asked of the provider with a computer generated response. If the provider needs to visit with a telephone service representative they may do so.

As a reminder to providers, securing the recipient ID card is the best way for you to obtain additional information on the benefits available to a recipient. Verification of eligibility is not a guarantee of claim payment. Providers should review the Provider Manuals and SD Administrative Rules available at

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South Dakota Electronic Health Record (EHR) Incentive Payment Program

South Dakota Medicaid continues to pay eligible providers and eligible hospitals as part of the South Dakota Electronic Health Record Incentive Payment Program which was established by the HITECH Act of 2009. The Medicaid EHR Incentive Payment Program provides incentive payments for eligible providers for adopting and meaningfully using certified EHRs.

The South Dakota EHR Portal has been updated so providers are now able to attest for program year 2013. Eligible hospitals must register and attest before December 31, 2013 in order to receive a payment for 2013 while eligible professionals have until March 30, 2014 to register and attest to receive a 2013 incentive payment.

Changes to program year 2013 affect the patient volume calculation, making it easier for providers to meet patient volume requirements. Expanded countable Medicaid visits are allowed in meeting patient volume and a more flexible timeframe is available to attest.

For specific 2013 Stage 1 details, please visit:

For assistance enrolling in or attesting for the EHR Payment Program, please contact HealthPOINT, the EHR resource and support center for South Dakota at (605) 256-5555 or

To learn more about the South Dakota EHR program, please review the South Dakota Medicaid EHR Incentive Payment program at

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Well-Child Visit Coverage

Regular well-child evaluations are a covered and encouraged service for children under South Dakota Medicaid and CHIP. It is important to be aware that this coverage is only available at the specified intervals noted on the periodicity schedule link located here:

After 3 years of age, these visits are only covered 1 time per year. If a recipient has received a well-child visit in the 365 days prior to their current visit, the claim will be denied due to this limitation. In order to avoid parent responsibility for these bills, please schedule yearly well-child evaluations for children age 3 and up after the 365 day from the previous year's well-child visit.

Please also be aware that this limit does not apply to visits for any medical ailments, suspected conditions or illnesses, or specific symptoms that need to be evaluated. There is no limitation on coverage for children's visits for these reasons. They can be billed using the standard E&M CPT codes and should not be billed as well-child visits.

For more information on coverage of well-child evaluations, visit

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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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