A claim submitted under this chapter must be submitted at the provider's usual and customary charge.

The laboratory that performed the laboratory test shall submit the claim for the test.

If relevant, the claim shall identify the modifying circumstance of a service or procedure by the addition of the applicable modifier code to the procedure code.

A claim submitted for multiple surgeries must contain the applicable procedure code for the primary surgical procedure. All other procedures performed during the same operating session must be billed using the applicable procedure code and modifier 51. A bilateral procedure or a surgical procedure which cannot stand alone but which is performed as a part of a primary surgical procedure is not considered a multiple surgical procedure.

A claim submitted by a clinical nurse specialist, a nurse practitioner, or a physician assistant must contain the nurse practitioner's, the clinical nurse specialist's, or the physician assistant's provider identification number and may not be submitted under the supervising physician's provider identification number.

A claim submitted for immunizations must contain the applicable procedure code for the administration of the vaccine and an additional procedure code for the vaccine itself. If the vaccine is supplied by the state, the billing code for the vaccine must contain the two-letter modifier of SL.

Cross-References:

Required modifier codes, § 67:16:02:03.03.

Third-party liability, ch 67:16:26.

Claims, ch 67:16:35.

Source: 16 SDR 234, effective July 2, 1990; 17 SDR 200, effective July 1, 1991; 1921 SDR 165, effective May 3, 1993; 23 SDR 38, effective September 26, 1996; 34 SDR 68, effective September 12, 2007; 44 SDR 94, effective December 4, 2017.

General Authority: SDCL 28-6-1 (1)(2) .

Law Implemented: SDCL 28-6-1 (1)(2) .

Prior versions effective: 2007-09-12.