Transcription
South Dakota MedicaidAuthorized ModifiersEffective 05/01/2018Updated 04/27/2022A modifier provides the means for a provider to indicate that a service or procedure wasaltered by a specific circumstance but not changed in its definition or code. Pursuant to ARSD67:16:02:03.03, modifier codes must be included on a provider's claim for services ifapplicable. Claims with modifiers not contained in this list may only be billed if the modifier isconsidered informational and does not reflect a reduction in services. Modifiers affectingpayment or included in this document must be listed first. All modifiers must be billed inaccordance with guidance in the CPT codebook or HCPCS Level II book unless otherwisestated in this document.Medical ServicesModifier Description22Increased Procedural ServicesPayment Effect125% Established Fee24No Established Fee 40% Usual andCustomary Charge(UCC)None25272632Unrelated Evaluation and Management Service by theSame Physician or Other Qualified Health CareProfessional During a Postoperative PeriodSignificant, Separately Identifiable Evaluation andManagement Service by the Same Physician or OtherQualified Health Care Professional on the Same Day ofthe Procedure or ServiceMultiple Outpatient Hospital E/M Encounters on theSame DateProfessional ComponentMandated ServicesService must meet medical necessity criteria.NoneNone30% Established Feefor laboratoryprocedures40% Established Feefor non-laboratoryproceduresNo Established Fee 40% UCCNoneSouth Dakota Medicaid Authorized Modifiers Updated: April 221
Modifier Description33Preventative ServicesPayment EffectNone47Anesthesia by SurgeonNone50Bilateral Procedure150% Established FeeMultiple ProceduresNo Established Fee 40% UCC50% Established Fee51No Established Fee 30% UCC52Reduced Services75% Established FeeNo Established Fee40% UCC53Discontinued Procedure50% Established FeeNo Established Fee40% UCC54Surgical Care Only75% Established FeeNo Established Fee40% UCC55Postoperative Management Only25% Established FeePreoperative Management OnlyNo Established Fee40% UCC25% Established Fee57Decision for SurgeryNo Established Fee40% UCCNone58Staged or Related Procedure by the Same Physician orOther Qualified Health Care Professional During thePostoperative Period56NoneSouth Dakota Medicaid Authorized Modifiers Updated: April 222
Modifier Description59Distinct Procedural ServicePayment Effect100% Established FeeNo Established Fee30% UCC62Two Surgeons50% Established Feefor each surgeonNo Established Fee 40% UCC6373Procedures Performed on Infants Less than 4 kgDiscontinued Out-Patient Hospital/Ambulatory SurgeryCenter (ASC) Procedure Prior to the Administration ofAnesthesiaNone50% Established FeeNo Established Fee 40% UCC74Discontinued Out-Patient Hospital/Ambulatory SurgeryCenter (ASC) Procedure After Administration ofAnesthesia50% Established FeeNo Established Fee 40% UCC76Repeat Procedure or Service by Same Physician orOther Qualified Health Care Professional100% Established FeeNo Established Fee 40% UCC77Repeat Procedure by Another Physician or OtherQualified Health Care Professional100% Established FeeNo Established Fee 40% UCC78Unplanned Return to the Operating/Procedure Room bythe Same Physician or Other Qualified Health CareProfessional Following the Initial Procedure for a RelatedProcedure During the Postoperative Period100% Established FeeNo Established Fee 40% UCCSouth Dakota Medicaid Authorized Modifiers Updated: April 223
Modifier Description79Unrelated Procedure or Service by the Same Physicianor Other Qualified Health Care Professional During thePostoperative PeriodPayment Effect100% Established FeeNo Established Fee 40% UCC808182Assistant Surgeon20% Established FeeMinimum Assistant SurgeonNo Established Fee 40% UCC20% Established FeeAssistant Surgeon when qualified resident surgeon notavailableNo Established Fee 40% UCC20% Established Fee90Reference (outside) LaboratoryNo Established Fee 40% UCCNone91Repeat Clinical Diagnostic Laboratory TestNone92Alternative Laboratory Platform TestingNone93None96Synchronous Telemedicine Service Rendered ViaTelephone or Other Real-Time Interactive Audio-OnlyTelecommunications SystemHabilitative services97Rehabilitative ServicesNoneASPhysician assistant, nurse practitioner, or clinical nursespecialist services for assistant at surgeryFSMedicare E/M services split or shared between aphysician and non-physician practitioner in a same groupfacility setting.Via interactive audio and video telecommunicationsystems.The GT modifier must be included for all servicesprovided via telemedicine.Less than bachelor’s degree level counselorsServices provided by a physical therapy assistant,occupational therapy assistant, or speech-languagepathologist assistant must be billed by the supervisingtherapist using the HM modifier.Drug or biological acquired with 340B drug pricingprogram discount.20% Established FeeNo Established Fee 40% UCCNoneGTHMJGNoneNone50% Established FeeClaim is DeniedSouth Dakota Medicaid Authorized Modifiers Updated: April 224
Modifier DescriptionJWDrug amount discarded/not administered to any patientPayment EffectClaim Pays at 0.Cannot be billed to therecipient.NonePOServices, procedures and/or surgeries provided at offcampus provider-based outpatient departmentsQ6Substitute physician or physical therapistClaim is DeniedQWClinical Laboratory Improvement Amendment (CLIA)waived test.Must be used by pharmacies when billing a Strep test orflu test. The claim must be submitted on a CMS 1500 orvia 837P.State supplied vaccineNoneSLVaccine pays at 0.Administration code isreimbursed.Claim is DeniedTBDrug or biological acquired with 340B drug pricingprogram discount, reported for informational purposes.TCTechnical component70% Established Feefor laboratoryprocedures60% Established Feefor non-laboratoryproceduresNo Established Fee 40% UCCUNGroup Supported EmploymentAppend to Family Support waiver services if applicable.NoneXESeparate encounter, a service that is distinct because itoccurred during a separate encounterNoneXPSeparate practitioner, a service that is distinct because itwas performed by a different practitionerNoneXSSeparate structure, a service that is distinct because itwas performed on a separate organ/structureNoneXUUnusual non-overlapping service, the use of a servicethat is distinct because it does not overlap usualcomponents of the main serviceNoneSouth Dakota Medicaid Authorized Modifiers Updated: April 225
Anatomic MLTRCRIRTTAT1T2T3T4T5T6T7T8T9DescriptionUpper left, eyelidLower left, eyelidUpper right, eyelidLower right, eyelidLeft hand, thumbLeft hand, second digitLeft hand, third digitLeft hand, fourth digitLeft hand, fifth digitRight hand, thumbRight hand, second digitRight hand, third digitRight hand, fourth digitRight hand, fifth digitLeft circumflex coronary arteryLeft anterior descending coronary arteryLeft main coronary arteryLeft Side - Used to identify items for the left side of thebodyRight coronary arteryRamus IntermediusRight Side- Used to identify items for the right side of thebodyLeft foot, great toeLeft foot, second digitLeft foot, third digitLeft foot, fourth digitLeft foot, fifth digitRight foot, great toeRight foot, second digitRight foot, third digitRight foot, fourth digitRight foot, fifth digitPayment DescriptionUnusual AnesthesiaPayment Effect100% Established FeeNo Established Fee 40% UCCSouth Dakota Medicaid Authorized Modifiers Updated: April 226
ModifierAADescriptionAnesthesia services performed personally byanesthesiologistPayment EffectNoneADMedical supervision by a physician: more than fourconcurrent anesthesia proceduresNoneQKMedical direction of two, three, or four concurrentanesthesia procedures involving qualified individualsNoneQXCRNA service: with medical direction by a physicianNoneQYMedical direction of one certified registered nurseanesthetist (CRNA) by an anesthesiologistNoneQZCRNA service: without medical direction by a physicianNoneP1A normal healthy patientNoneP2A patient with mild systemic diseaseNoneP3A patient with severe systemic diseaseNoneP4A patient with severe systemic disease that is a constantthreat to lifeNoneP5A moribund patient who is not expected to survivewithout the operationNoneP6A declared brain-dead patient whose organs are beingremoved for donor purposesNot coveredBehavioral HealthModifierAMEYGTDescriptionPhysician, team member servicePsychiatric ServiceNo physician or other licensed health care provider orderfor this item or serviceSocial detox; City/County Meth Program OnlyVia interactive audio and video telecommunicationsystems.The GT modifier must be included for all servicesprovided via telemedicine.Payment EffectSee Behavioral HealthFee SchedulesSee Behavioral HealthFee SchedulesNoneSouth Dakota Medicaid Authorized Modifiers Updated: April 227
ModifierHAHBDescriptionChild/adolescent programSubstance Use Disorder Providers should use the HAmodifier to indicate child or adolescent program.Payment EffectSee Behavioral HealthFee SchedulesCMHCs should use the HA modifier to indicatePsych/CNP CYF services and for MRT/ART services andassessments.Adult program, non-geriatricSee Behavioral HealthCARE modifier for Psych/CNP services.Fee SchedulesHDPregnant/parenting women's programSee Behavioral HealthFee SchedulesHEMental health programSubstance Use Disorder Providers should use the HEmodifier to indicate an individual service.See Behavioral HealthFee SchedulesHFHGHKCMHCs should use the HE modifier to indicate aManaged Care Exemption when providing a mentalhealth service.Substance abuse program2.1/3.1 services; used for individuals receiving residentialand outpatient servicesSee Behavioral HealthFee SchedulesFQHCs and IHS/Tribal 638s programs enrolled as asubstance use disorder agency must use the HF modifierfor substance use disorder services in order to be paid atthe encounter rate.Opioid addiction treatment programSee Behavioral HealthIntensive Meth Treatment Program; SD Women’s Prison. Fee SchedulesSpecialized mental health programs for high-riskpopulationsIMPACT modifier for Psych/CNP services. Also used incombination with “HA” to identify ART services.Group settingSee Behavioral HealthFee SchedulesHVFunded state addictions agencyGambling ServicesSee Behavioral HealthFee SchedulesHWFunded by state mental health agencyTransitional CARE.See Behavioral HealthFee SchedulesSANurse practitioner rendering service in collaboration witha physicianPhysician Assistant, Nurse Practitioner, Clinical NurseSpecialist.See Behavioral HealthFee SchedulesHQSee Behavioral HealthFee SchedulesSouth Dakota Medicaid Authorized Modifiers Updated: April 228
ModifierSEDescriptionState and/or federally-funded programs/servicesLCBHS Impact.Payment EffectSee Behavioral HealthFee SchedulesTNRural/outside providers' customary service areaSee Behavioral HealthFee ct procedural servicesDHDiagnostic/therapeutic site other than physician’soffice/hospital to a hospitalDiagnostic/therapeutic site other than physician’soffice/hospital to a scene of accident/acute eventResidential, domiciliary, or custodial facility to a hospitalHospital-based dialysis facility to a hospitalMultiple patients on one ambulance trip.Providers must submit the appropriate origin anddestination modifiers in the first modifier position andHCPCS modifier GM in the second modifier position.If a provider must bill Medicare for a denialHospital to a diagnostic/therapeutic site other thanphysician’s office/hospitalHospital to a residential, domiciliary, or custodial facilityHospital to a hospital-based dialysis facilityHospital to another hospitalHospital to a site of ambulance transport modes transferHospital to a non-hospital-based dialysis facilityHospital to a skilled nursing facilityHospital to a physician's officeHospital to residenceHospital to a scene of accident or acute eventSite of ambulance transport modes transfer to aresidential, domiciliary, or custodial facilitySite of ambulance transport modes transfer to a hospitalSite of ambulance transport modes transfer to anothersite of ambulance transport modes transferSite of ambulance transport modes transfer to a skillednursing facilityNon-hospital-based dialysis facility to a hospitalSkilled nursing facility to a hospital-based dialysis facilitySkilled nursing facility to a NHPayment Effect100% of theEstablished FeeNoneNoneNoneNoneNoneClaim is NoneNoneNoneNoneNoneNoneSouth Dakota Medicaid Authorized Modifiers Updated: April 229
criptionSkilled nursing facility to another skilled nursing facilitySkilled nursing facility to a physician's officeSkilled nursing facility to a residencePhysician's office to a hospitalPhysician's office to a site of ambulance transport modestransferPhysician's office to a residencePatient pronounced dead after ambulance calledDo not bill for the service if the recipient dies beforebeing transported and no medically necessary serviceswere provided at the scene. It is recommended theprovider include a trip report with the claim.Hospital arranged secure medical transportationAmbulance furnished by providerResidenceResidence to a Diagnostic/therapeutic site other thanphysician’s office/hospitalResidence to a residential, domiciliary, or custodialfacilityResidence to a hospitalResidence to a site of ambulance transport modestransferResidence to a skilled nursing facilityResidence to a Physician's officeScene of Accident/Acute Event to HospitalScene of Accident/Acute Event to another Scene ofAccident/Acute EventExtra patient or passenger, non-ambulanceRural/outside providers' customary service areaPayment EffectNoneNoneNoneNoneNoneNoneNone150% Established FeeNoneNoneNoneNoneNoneNoneNoneNoneNoneNone50% Established Fee150% Established FeeDurable Medical Equipment, Prosthetics, Orthotics, and NutritionCodeAVBOJWLTNURBDescriptionItems furnished in conjunction with a prosthetic devise,prosthetic or orthoticOrally administered nutrition, not by feeding tubeDrug amount discarded/not administered to any patientLeft SideUsed to identify items for the left side of the bodyNew EquipmentReplacement of a part of a DME, orthotic or prostheticitem furnished as part of a repairPayment EffectNoneNoneClaim Pays at 0.Cannot be billed to therecipient.NoneNoneNoneSouth Dakota Medicaid Authorized Modifiers Updated: April 2210
CodeRRRTUEDescriptionRentalUse the RR modifier when the DME is rentedRight SideUsed to identify items for the right side of the bodyUsed Durable Medical Equipment (DME)Payment EffectNoneNoneNoneSouth Dakota Medicaid Authorized Modifiers Updated: April 2211
South Dakota Medicaid Authorized Modifiers Updated: April 22 1 South Dakota Medicaid Authorized Modifiers Effective 05/01/2018 Updated 04/27/2022 A modifier provides the means for a provider to indicate that a service or procedure was altered by a specific circumstance but not changed in its definition or code. . RI Ramus Intermedius None .
