Cabinet Secretary
Matt Althoff

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Medicaid Provider Diagnosis Look-Up Tool

The Diagnosis Look-up Tool can be used by providers to identify the circumstances when a diagnosis code is payable by South Dakota Medicaid. Providers should review all fields to determine if a code is payable. The status indicated on the tool is not a guarantee of payment. Claims may deny for other reasons such as system edits or failure to meet South Dakota Medicaid coverage criteria. A description of the fields is provided below.

Diagnosis Code: This is the ICD-10 diagnosis code.

Diagnosis Description: This is a description of the diagnosis code.

Billing Status

  • Primary: This code may be listed first on a claim. Multiple primary codes may be listed.
  • Secondary: This code may not be listed first on the claim and must be billed in conjunction with a primary code. Multiple secondary codes may be listed.
  • Not Covered: This code is not billable per ICD-10 rules or South Dakota Medicaid coverage criteria.

Requires Review

  • Yes: This code is subject to review by South Dakota Medicaid staff and the provider may be required to submit supporting documentation.

Minimum Age and Maximum Age: The recipient’s age on the date of service must be within this age range. If the recipient is younger than the minimum age on the date of service, the code is not payable. If the recipient is older than the maximum age on the date of service, the code is not payable. Codes with a minimum age of “0” and a maximum age of “0” are limited to recipients younger than 12 months and are payable if the diagnosis description indicates it is appropriate for the recipient.

Mental Health

  • Yes: This code is payable for independent mental health practitioners. Diagnosis codes for intellectual disability and substance use disorders may only be billed as a secondary diagnosis for independent mental health services. The following are considered independent mental health practitioners: Certified Social Worker – Private Independent Practice (PIP), Certified Social Worker – PIP candidate, Certified Nurse Specialist, Licensed Marriage and Family Therapist, Licensed Professional Counselor – Mental Health, Licensed Professional Counselor working toward a Mental Health designation, or Licensed Psychologist.
  • No: This code is not payable for independent mental health practitioners.

SUD

  • Yes: This code is payable for substance use disorder treatment agencies.
  • No: This code is not payable for substance use disorder treatment agencies.

Chiropractor

  • Yes - Primary: This code is payable for chiropractors when used as the primary diagnosis.
  • Yes - Secondary: This code is payable for chiropractors when used as the secondary diagnosis.
  • No: This code is not payable for chiropractors.

Community Health Worker (CHW)

  • Yes - Primary: This code is payable for CHWs when used as the primary diagnosis.
  • Yes - Secondary: This code is payable for CHWs when used as the secondary diagnosis.
  • No: This code may be used as a primary diagnosis if the billing status column indicates “Primary”. This code may be used as a secondary diagnosis code if the billing status column indicates “Secondary”

Start Date and End Date: The date of service must be within this date span for the code to be payable. If the end date is “12/31/9999” the code is an active ICD-10 diagnosis code and has no end date. Claims must be submitted within South Dakota Medicaid’s timely filing standards. Refer to the General Claims Guidance manual for more information about timely filing.

Please note that information displayed on the tool is not a guarantee of payment. Claims may deny for other reasons such as system edits or services not meeting South Dakota Medicaid coverage criteria.

License for Use of Physicians' Current Procedural Terminology (CPT)

End User Point and Click Agreement

Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2015 American Medical Association (AMA).
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.


Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 515 North State Street, Chicago, IL 60610. Applications are available on the AMA website, https://www.ama-assn.org/practice-management/cpt/ama-cpt-licensing-overview

Applicable FARS/DFARS restrictions apply to government use. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60654. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-l(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

AMA Disclaimer of Warranties and Liabilities
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer
The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

Should the foregoing terms and conditions be acceptable to you, indicate your agreement and acceptance by clicking on the button labeled "I ACCEPT."

Point and Click License for Use of Current Dental Terminology (CDT™)
End User License Agreement

These materials contain Current Dental Terminology (CDT™), Copyright © 2015 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED “I ACCEPT,” YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED “I DO NOT ACCEPT” AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, “YOU” AND “YOUR” REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website: http://www.ADA.org/.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. This product includes Current Dental Terminology ("CDT'"), which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago, Illinois, 60611. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-l(a) (June 1995) and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT IS PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESSED OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. NO FEE SCHEDULES, BASIC UNIT, RELATIVE VALUES, OR RELATED LISTINGS ARE INCLUDED IN CDT. THE ADA DOES NOT DIRECTLY OR INDIRECTLY PRACTICE MEDICINE OR DISPENSE DENTAL SERVICES. THE SOLE RESPONSIBILITY FOR THE SOFTWARE, INCLUDING ANY CDT AND OTHER CONTENT CONTAINED HEREIN, IS WITH XEROX STATE HEALTHCARE, LLC OR THE CMS; AND NO ENDORSEMENT BY THE ADA IS INTENDED OR IMPLIED. THE ADA EXPRESSLY DISCLAIMS RESPONSIBILITY FOR ANY CONSEQUENCES OR LIABILITY ATTRIBUTABLE TO OR RELATED TO ANY USE, NON-USE, OR INTERPRETATION OF INFORMATION CONTAINED OR NOT CONTAINED IN THIS FILE/PRODUCT. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End users do not act for or on behalf of CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. IN NO EVENT SHALL CMS BE LIABLE FOR DIRECT, INDIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES ARISING OUT OF THE USE OF SUCH INFORMATION OR MATERIAL.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, indicate your agreement by clicking on the button labeled “I ACCEPT.” If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click on the button labeled “I DO NOT ACCEPT” and exit from this computer screen.