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. 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.

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.