Last updated 08/23/2024
Email, Phone & Fax
For distant site services billed on a CMS 1500 or 837P providers must bill;
- “02” for telemedicine services provided other than in patient’s home;
- “10” for telemedicine services provided in the patient’s home; or
- “77” for audio-only services.
Telemedicine Modifiers – Telemedicine provided at a distant site must be billed with the GT modifier in the first modifier position to indicate the service was provided via telemedicine/audio-only. Failure to comply with this requirement may lead to payment recoupment or other action as decided by South Dakota Medicaid.
Audio-Only Modifier
- CMHC and SUD Agencies: Bill modifier GT in addition to the POS code 77.
- All other providers allowed to bill audio only services: Bill modifier 93 in addition to the POS code 77.
Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Jul. 2024) (Accessed Jul. 2024).
Audio-Only Behavioral Health Services
South Dakota Medicaid covers real time, two-way audio-only behavioral health services delivered by a Substance Use Disorder (SUD) Agency or a Community Mental Health Center (CMHC) when the recipient does not have access to face-to-face audio/visual telemedicine technology.
South Dakota Medicaid covers real-time, two-way audio-only behavioral health services delivered by an Independent Mental Health Practitioner (IMHP) when the recipient does not have access to face-to-face audio/visual telemedicine technology.
SUD agencies and CMHCs, and IMHPs must utilize traditional audio/visual telemedicine technology when possible. Audio-only services are not covered when used for the convenience of the provider or recipient. The provider must document in the medical record that the use real time video/audio technology was not possible or was unsuccessful.
Covered Services – CMHCs may provide all covered services via audio-only technology when coverage requirements are met. SUD agencies may only provide covered SUD agency services listed in the Audio-Only Procedure Code table in the Appendix via audio-only technology when the coverage requirements are met. Contact the Division of Behavioral Health for questions regarding unlisted codes.
For the purpose of this manual, an IMHP includes mental health providers who meet the requirements in ARSD 67:16:41:03 and licensed physicians or psychiatrists that provide behavioral health services. IMHPs may provide applicable services listed in the Audio-Only Procedure Code table in the Appendix via audio-only technology when the coverage requirements are met. Services not listed in the table are not allowed to be provided via telemedicine or audio-only technology. An IMHP cannot bill the following CPT codes: 98966, 98967, and 98968.
FQHCs/RHCs and IHS/Tribal 638 Providers – SUD agency services may also be provided via audio-only if the provider is an accredited and enrolled agency. Audio-only behavioral health services are reimbursed at the encounter rate.
Non-covered Services – Services other than those specifically stated as covered when provided via an audio-only modality are considered non-covered if provided via an audio-only modality and must not be billed to South Dakota Medicaid.
Claim Instructions – Audio-only services will need the GT modifier and place of service 77. Any additional modifiers must be coded alphabetically as shown on the CMHC and SUD fee schedules.
Audio-Only Community Health Worker Services – Community Health Worker (CHW) services must be related to an intervention outlined in the individual’s CHW Service Plan. Service may be provided via two-way audio-only when the recipient does not have access to audio/visual telemedicine technology. The limitation necessitating audio-only services must be documented in the recipient’s record.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Jul. 2024), pg. 9-10, (Accessed Jul. 2024).
Audio-Only Evaluation and Management Services
Audio-only evaluation and management services are covered for established patients if the recipient does not have access to face-to-face audio/visual telemedicine technology. The provider must document in the medical record that the use of real time video/audio technology was not possible or was unsuccessful.
The service must be initiated by the recipient. The service should include patient history and/or assessment, and some degree of decision making. Telephonic evaluation and management services are only allowed to be provided by a physician, podiatrist, nurse practitioner, physician assistant, or optometrist. The service must be 5 minutes or longer. Services may be provided via telephone or via another device or service that allows real-time audio communication.
Audio-only evaluation and management services are not to be billed if clinical decision-making dictates a need to see the patient for an office visit, including a telemedicine office visit, within 24 hours or at the next available appointment time. In those circumstances, the telephone service is considered a part of the subsequent office visit. If the telephone call follows a billable office visit performed in the past seven calendar days for the same or a related diagnosis, then the telephone services are considered part of the previous office visit and are not separately billable. Telephone services provided by an RN or LPN are not billable.
Non-Covered Services: Audio-only services are only covered if initiated by a recipient and the recipient did not have access to face-to-face audio/visual telemedicine technology.
Claims Instructions: Services must be billed using CPT codes 98966, 98967, and 98968. Providers should select the appropriate code based on the time associated with the service. Do not bill for these services using CPT codes 99441, 99442, or 99443 even if you believe the code description is more applicable. Billing with 99441, 99442, or 99443 will result in your claim being denied.
Reimbursement – Payment for services is limited to the lesser of the provider’s usual and customary charge or the fee contained on South Dakota Medicaid’s Physician Services fee schedule. FQHC/RHC and IHS/Tribal 638 providers may bill for audio-only evaluation and management services using codes 98966, 98967, and 98968 and be reimbursed at the fee schedule rate. These services must be submitted using the FQHC/RHCs non-PPS billing NPI. For more information regarding billing with a non-PPS NPI please refer to the FQHC/RHC Service Manual.
Billing a Recipient – There is no cost share for this service. Please refer to our Billing a Recipient Manual for additional requirements a provider must meet to bill a recipient.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 10-11 (Jul. 2024), (Accessed Jul. 2024).
Crisis assessment and intervention services. An immediate therapeutic response available 24 hours a day 7 days a week that involves direct telephone or face-to-face contact with a recipient exhibiting acute psychiatric symptoms and/or inappropriate behavior that left untreated, presents an immediate threat to the recipient or others.
SOURCE: SD Medicaid Billing and Policy Manual: Community Mental Health Center Services, p. 5 (Apr. 2024), (Accessed Jul. 2024).
Collateral Contacts are telephone, telemedicine or face-to-face contact with an individual other than the recipient receiving treatment in an outpatient setting. The contact may be with a spouse, family member, guardian, friend, teacher, healthcare professional, or other individual who is knowledgeable of the recipient receiving treatment. Collateral must be for the direct benefit of the beneficiary.
SOURCE: SD Medicaid Billing and Policy Manual: Community Mental Health Center Services, p. 8 (Apr. 2024) & Substance Use Disorder Agency Services, p. 8 (Dec. 2023) (Accessed Jul. 2024).
Physician Services:
- Anticoagulant management (CPT codes 93792 and 93793), physician telephone patient services (CPT codes 99441-99443), online medical evaluation (CPT code 99444), interprofessional telephone/internet/electronic health record consultations (CPT codes 99446-99449 and 99451-99452), disability evaluation services (CPT codes 99450, 99455, 99456), care management services (CPT codes 99487-99496), and behavioral health integration care management (CPT code 99484);
SOURCE: SD Medicaid Billing and Policy Manual: Physician Services, p. 12 (Apr. 2024), (Accessed Jul. 2024).
Teledentistry
Synchronous teledentistry services may not be provided via email, audio-only, or facsimile transmissions.
SOURCE: SD Medicaid Billing and Policy Manual, Teledentistry Services, p. 4, (Jun. 2023), (Accessed Jul. 2024).
Pregnancy Program
Pregnancy Program providers agree to provide for reasonable and adequate hours of operation and make available 24-hour, 7 days per week access by telephone for information, referral, and treatment needs during non-office hours. In addition, they agree to provide services via audio-only or telemedicine modalities if appropriate.
SOURCE: SD Medicaid Billing and Policy Manual, Pregnancy Services, p. 8, (Aug. 2024), (Accessed Jul. 2024).
Primary Care Provider Program
PCPs must provide 24-hour, 7 day a week access by telephone which will immediately page an on-call medical professional to handle medical situations during non-office hours. If affiliated with a calling network to serve as the non-office hour’s contact, this may not be utilized for PCP referral. Any referrals given to recipients through these calling networks (e.g., referring individuals to seek medical attention at the emergency room) must be approved by the recipient’s PCP or the Designated Covering Provider (DCP). Referrals may be made by the recipient’s PCP or DCP retroactively if appropriate. Refer to the Referrals manual for additional information.
SOURCE: SD Medicaid Billing and Policy Manual, Primary Care Provider Program, p. 2, (Jun. 2024), (Accessed Jul. 2024).
CHOICES Waiver
Supported living services are reimbursed at a 15-minute unit rate. Please refer to the CHOICES Fee Schedule for detailed rates.
A portion of this service can be delivered virtually, which includes but is not limited to:
- The use of telephonic/virtual supports through FaceTime, Zoom, Echo or other means of telecommunication to provide verbal prompting for a participant and/or their support person to provide personal care supports to perform activities of daily living.
- The use of telephonic/virtual supports through FaceTime, Zoom, or Echo other means of telecommunication to continue to support participants with medication management.
- Check-in phone calls are considered a case management function and would not be considered telephonic/virtual habilitative supports.
Remote Day Services are reserved for outstanding circumstances that restrict a participant’s access to Facility and/or Community Support Day Services. The following examples are types of virtual day services:
- The use of telephonic/virtual supports through Facetime, Zoom, Echo, or means of telecommunication to promote socialization that aligns with ISP goals. CSPs can use technology to promote and support social interaction through “virtual hangouts” for participants to engage with their friends and other natural supports.
- Utilizing technology to support individuals to access community events that they previously engaged in. Examples of this may include supporting participants to access online church services, remote book clubs, etc.
SOURCE: SD Medicaid Billing and Policy Manual, CHOICES Waiver, p. 5-6 & 10, (Feb. 2024), (Accessed Jul. 2024).
Inpatient Hospital Services
An individual’s psychiatric care is a covered service if the hospital received authorization for the admission under ARSD 67:16:40:04 and the following conditions are met:
- A physician completed a medical assessment of the individual and had at least a telephone consultation with a psychiatrist. The psychiatric consultation or diagnosis must include a treatable mental health condition. An admission is not allowed on the basis of a previous diagnosis if symptoms associated with the diagnosis are not active at the time of the admission (see manual for more requirements)
SOURCE: SD Medicaid Billing and Policy Manual, Inpatient Hospital Services, p. 7, (Sept. 2023), (Accessed Jul. 2024).
Independent Mental Health Practitioners
Collateral Contacts are telephone, telemedicine, or face-to-face contact with an individual other than the recipient receiving treatment in an outpatient setting. The contact may be with a spouse, family member, guardian, friend, teacher, healthcare professional external to behavioral health, or other individual who is knowledgeable of the recipient receiving treatment. Collateral must be for the direct benefit of the beneficiary.
IMHP Non-Covered Services
- Mental health treatment provided without the recipient physically present in a face-to-face or telehealth session with the mental health provider except for telehealth treatment and collateral contacts. …
- Telephone consultations with or on behalf of the recipient except for collateral contact.
SOURCE: SD Medicaid Billing and Policy Manual: Independent Mental Health Practitioners (Apr. 2024), (Accessed Jul. 2024).
Pharmacy Services
South Dakota regulation does not require a pharmacist to document counseling that was accepted or offered. The absence of a record signifies counseling was accepted and provided or that an offer was made. Failure to complete counseling shall be recorded for the following instances. …
- Counseling could not be accomplished by telephone contact.
SOURCE: SD Medicaid Billing and Policy Manual: Pharmacy Services (Jun. 2024), pg. 6, (Accessed Jul. 2024).
Last updated 07/23/2024
Live Video
POLICY
Providers should refer to the General Coverage Principles manual for basic coverage requirements all services must meet. These coverage requirements include:
- The provider must be properly enrolled;
- Services must be medically necessary;
- The recipient must be eligible; and
- If applicable, the service must be prior authorized.
The manual also includes non-discrimination requirements providers must abide by.
Services provided via telemedicine are subject to the same service requirements and limitations as in person services. Providers must have and utilize appropriate equipment to provide a service via telemedicine. Telemedicine services always involve an originating site and a distant site.
Providers must bill for services at their usual and customary charge. Providers are reimbursed the lesser of their usual and customary charge or the fee schedule rate.
Reimbursement for distant site telemedicine services is limited to the individual practitioner’s professional fees or the encounter rate if the service qualifies as an FQHC/RHC or IHS/Tribal 638 clinic service. The maximum allowable reimbursement for distant site services is listed on the applicable fee schedule. The maximum allowable amount for services provided via telemedicine is the same as services provided in-person. Facility related charges for distant site telemedicine providers are not reimbursable.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 3 & 12 (Jul. 2024) (Accessed Jul. 2024).
Services provided via teledentistry must meet the applicable standard of care. When reporting a service completed via teledentistry, providers are certifying the services rendered to the recipient were functionally equivalent to services provided through a face-to-face visit. Services provided via teledentistry must be provided in accordance with the coverage criteria in the adult and children dental provider manuals. Synchronistic services must be of sufficient audio and visual fidelity and clarity to be functionally equivalent to a face-to-face encounter.
Services provided via teledentistry should include the following additional documentation in addition to the standard of service documentation:
- If synchronistic, the name of the platform used to complete the visit; and
- Detailed clinical notes of the visit including the name and credentials of individuals involved in the teledentistry visit and their role in the visit.
SOURCE: South Dakota Medicaid Billing and Policy Manual, Teledentistry Services, pg. 3 (Jun. 2023) (Accessed Jul. 2024).
ELIGIBLE SERVICES/SPECIALTIES
Only certain procedure codes may be provided via telemedicine. Refer to the Appendix for a list of procedure codes allowed to be provided via telemedicine.
Applied Behavioral Analysis (ABA) Services – ABA services may be provided via telemedicine. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter. Please refer to the Applied Behavioral Analysis (ABA) Services manual for additional coverage information.
Audiology Services – Limited fitting and programming audiology services may be provided via telemedicine. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter. The following services may be performed when the patient is in any setting, including the patient’s home:
- Cochlear Implant Follow-Up/Reprogramming (CPT codes 92601-92604);
- Hearing Aid Checks (CPT codes 92592-92593), and
- Auditory Function Evaluation (CPT codes 92620, 92621, 92626, and 92627).
In addition, the following services can be provided via telemedicine when the patient is located in a clinic or other setting with a qualified health professional present:
- Tympanometry (CPT code 92550 and 92567); and
- Evoked Auditory Tests (CPT codes 92585-92588).
Please refer to the Audiology Services manual for additional coverage information.
Diabetes Self-Management Training (DSMT) – When applicable, the distant site practitioner must confirm that the recipient has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year’s 2 hours of follow-up training.
Please refer to the Diabetes Self-Management Training Services manual for additional coverage information.
End-Stage Renal Disease (ESRD) Services – ESRD services must include at least 1 visit per month be furnished face-to-face “hands on” to examine the vascular access site by a physician other licensed practitioner. Telemedicine may be used for providing additional visits
Emergency Department or Initial Inpatient Consultation – The intent of an inpatient or emergency department telemedicine consultation service is that a physician or other licensed practitioner or other appropriate source is asking another physician or other licensed practitioner for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.
A request for an inpatient or emergency department telemedicine consultation from an appropriate source and the need for an inpatient or emergency department telemedicine consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or other licensed practitioner plan of care in the patient’s medical record.
Inpatient and Nursing Facility Telemedicine – Inpatient telemedicine consultations furnished to recipients in hospitals or skilled nursing facilities via telemedicine must be at the request of the physician of record, the attending physician, or another appropriate source. The physician or practitioner who furnishes the initial inpatient consultation via telemedicine cannot be the physician or practitioner of record or the attending physician or practitioner, and the initial inpatient telemedicine consultation would be distinct from the care provided by the physician or practitioner of record or the attending physician or practitioner. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patient’s needs.
Teledentistry Services – Please refer to the Teledentistry Services manual for information regarding coverage of teledentistry services.
Therapy Services – Physical therapy, occupational therapy, and speech language therapy services may be provided via telemedicine. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter.
Telemedicine service for electric stimulation attended, code 97032, is limited to one unit. Providers must document any treatment modifications used to support delivering services via telemedicine. Please refer to the Therapy Services manual for additional coverage information.
School District Services – School district providers may provide physical and occupational therapy via telemedicine using CPT code 97799 for physical therapy and CPT code 97139 for occupational therapy. Speech-language pathology services continue to be allowed when provided via telemedicine and should be billed using CPT code 92507. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter.
Psychology services may also be provided via telemedicine or real time, two-way audio-only using CPT code 90899. Audio-only services must be provided in accordance with the independent mental health practitioner coverage criteria stated in this manual.
Please refer to the School District Services manual for additional coverage information.
Services not specifically listed as covered in the procedure code table in the Appendix are considered non-covered. Claims submitted by a non-eligible originating site will be denied. Birth to Three services do not qualify for an originating site reimbursement unless provided at an eligible originating site location. Distant sites located outside of the United States are not covered.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Jul. 2024). (Accessed Jul. 2024).
Can ABA services be provided via telemedicine? Yes, South Dakota Medicaid allows ABA services to be provided via telemedicine. Refer to the Telemedicine manual for coverage details.
SOURCE: SD Medicaid Billing and Policy Manual: Applied Behavior Analysis, p. 7 (Dec. 2023). (Accessed Jul. 2024).
Can speech therapy be provided via telemedicine? Yes, speech therapy services may be provided via telemedicine once an initial in-person contact has been completed. An in-person contact must occur every 90 days thereafter. The telemedicine service must be provided by means of “real-time” interactive telecommunications system.
SOURCE: SD Medicaid Billing and Policy Manual: Therapy Services, pg. 8, (Dec. 2023), (Accessed Jul. 2024).
Speech language pathologist services can be provided via telemedicine if it meets the requirements in the in the Telemedicine manual.
SOURCE: SD Medicaid Billing and Policy Manual: Birth to Three Non-School District Providers, p. 3, (Sept. 2022), (Accessed Jul. 2024).
Refer to the Telemedicine manual regarding speech language pathology, occupational therapy, physical therapy, and psychology services that may be provided via telemedicine.
SOURCE: SD Medicaid and Policy Manual: School Districts, pg. 5, (Aug. 2024), (Accessed Jul. 2024).
Services provided via teledentistry must meet the applicable standard of care. When reporting a service completed via teledentistry, providers are certifying the services rendered to the recipient were functionally equivalent to services provided through a face-to-face visit. Services provided via teledentistry must be provided in accordance with the coverage criteria in the adult and children dental provider manuals. Synchronistic services must be of sufficient audio and visual fidelity and clarity to be functionally equivalent to a face-to-face encounter.
See manual for list of codes.
SOURCE: SD Medicaid Billing and Policy Manual, Teledentistry Services, p. 2, (Jun. 2023), (Accessed Jul. 2024).
CHW Services must be related to an intervention outlined in the individual’s CHW Service Plan. Service may be provided face-to-face, via telemedicine, or via two-way audio-only when the recipient does not have access to audio/visual telemedicine technology. The limitation necessitating audio-only services must be documented in the recipient’s record. Up to five (5) units of individual services may be performed in a clinic setting in a plan year to allow for the initial establishment of CHW/recipient relationship after which services are only allowed to be provided in a home or community setting. A CHW may attend medical appointments with a recipient. Group services may take place in a meeting room of a medical setting. The CHW Service Plan must be finalized prior to CHW services being rendered.
Covered services include:
- Health system navigation and resource coordination including helping a recipient find Medicaid providers to receive a covered service, helping a recipient make an appointment for a Medicaid covered service, arranging transportation to a medical appointment, attending an appointment with the recipient for a covered medical service, helping a recipient find other relevant community resources and programs such as support groups, food pantries, or utilities assistance programs, and implementing a component of the CHW Service Plan addressing a Social Determinant of Health (SDoH). In order to attend an appointment with a recipient the CHW must have written consent from the recipient
- Health promotion and coaching including providing information or education to recipients that makes positive contributions to their health status such as cessation of tobacco use, reduction in the misuse of alcohol or drugs, improvement in nutrition, improvement of physical fitness, family planning, control of stress, pregnancy and infant care including prevention of fetal alcohol syndrome.
- Health education to teach or promote methods and measures that have been proven effective in avoiding illness and/or lessening its effects such as immunizations, control of high blood pressure, control of sexually transmittable disease, prevention and control of diabetes, control of toxic agents, occupational safety and health, and accident prevention. The content of the education must be consistent with established or recognized healthcare standards.
Services may be provided to the parent or legal guardian of a recipient 18 or younger if the service is for the direct benefit of the recipient, in accordance with the recipient’s needs and CHW Service Plan objectives, and for the purpose of addressing the diagnosis identified in the CHW Service Plan
SOURCE: SD Medicaid Billing and Policy Manual: Community Health Worker, pg. 4, (Dec. 2023). (Accessed Jul. 2024).
Non-covered service
- Mental health treatment provided without the recipient physically present in a face-to-face or telehealth session with the mental health provider except for telehealth treatment and collateral contacts.
Mental health services provided after the third face-to-face or telehealth session with the recipient without a supporting treatment plan meeting the above requirements of this section are non-covered services.
A provider may not submit a claim for mental health services provided after the third face-to-face or telehealth session with a recipient and before the effective date of the treatment plan
“Psychotherapy,” the face-to-face or telehealth treatment of a recipient through a psychological or psychiatric method. The treatment is a planned, structured program based on a primary diagnosis of mental disorder and is directed to influence and produce a response for a mental disorder and to accomplish measurable goals and objectives specified in the recipient’s individual treatment plan;
May psychotherapy be provided via telehealth? Does telehealth meet the definition of face-to-face?
Yes, telehealth services are considered face-to-face. Psychotherapy is allowed to be provided via telehealth. Please review the telehealth chapter for more information about telehealth requirements.
SOURCE: SD Medicaid Billing and Policy Manual: Independent Mental Health Practitioners (Apr. 2024), (Accessed Jul. 2024).
An encounter for the initial ordering of durable medical equipment may occur through telehealth.
SOURCE: SD Medicaid Billing and Policy Manual: Durable Medical Equipment, Prosthetics, Orthotics and Supplies, pg. 2. Jun. 2024. (Accessed Jul. 2024).
A face-to-face encounter for physician recertification for hospice may occur via telemedicine.
SOURCE: SD Medicaid Billing and Policy Manual: Hospice, p. 2 (Jan. 2024), (Accessed Jul. 2024).
Telemedicine consultation services are covered as outpatient hospital services.
SOURCE: SD Medicaid Billing and Policy Manual: Outpatient Hospital Services, p. 2 (Jun. 2024), (Accessed Jul. 2024).
“Visit,” a face-to-face or telehealth encounter between a federally qualified health center or rural health clinic patient and a physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse, mental health provider listed in ARSD 67:16:41:03, dentist, or an accredited substance use disorder provider.
SOURCE: SD Medicaid Billing and Policy Manual: FQHC and RHC Services, pg. 7, (Jun. 2024), (Accessed Jul. 2024).
Home Health
For the initial order for home health services, a physician or other licensed practitioner must document a face-to-face encounter related to the primary reason the beneficiary requires the services. The encounter may occur through telemedicine. The encounter must occur within the 90 days before or 30 days after the start of the services.
SOURCE: SD Medicaid Billing and Policy Manual: Home Health Agency Services, p. 2 (Feb. 2024). (Accessed Jul. 2024).
Physician Administered Drugs – Pediatric Vaccination Counseling
A total of six counseling sessions (three for each code) per recipient, per calendar, year are reimbursable. Counseling may be provided via telemedicine. Counseling may also be provided via audio only if the visit was initiated by the recipient and the recipient does not have access to face-to-face audio/visual telemedicine technology. Telemedicine and audio only services must be billed in accordance with the Telemedicine Services billing manual.
SOURCE: SD Medicaid Billing and Policy Manual: Physician Administered Drugs, p. 5 (Mar. 2024). (Accessed Jul. 2024).
Diabetes Self-Management Training
Refer to the Telemedicine manual for guidance regarding providing services via telemedicine.
SOURCE: SD Medicaid Billing and Policy Manual: Diabetes Self-Management Training, pg. 2, (Jan. 2024), (Accessed Jul. 2024).
CHOICES Waiver
Supported living services are reimbursed at a 15-minute unit rate. Please refer to the CHOICES Fee Schedule for detailed rates.
A portion of this service can be delivered virtually, which includes but is not limited to:
- The use of telephonic/virtual supports through FaceTime, Zoom, Echo or other means of telecommunication to provide verbal prompting for a participant and/or their support person to provide personal care supports to perform activities of daily living.
- The use of telephonic/virtual supports through FaceTime, Zoom, or Echo other means of telecommunication to continue to support participants with medication management.
- Check-in phone calls are considered a case management function and would not be considered telephonic/virtual habilitative supports.
Remote Day Services are reserved for outstanding circumstances that restrict a participant’s access to Facility and/or Community Support Day Services. The following examples are types of virtual day services:
- The use of telephonic/virtual supports through Facetime, Zoom, Echo, or means of telecommunication to promote socialization that aligns with ISP goals. CSPs can use technology to promote and support social interaction through “virtual hangouts” for participants to engage with their friends and other natural supports.
- Utilizing technology to support individuals to access community events that they previously engaged in. Examples of this may include supporting participants to access online church services, remote book clubs, etc.
SOURCE: SD Medicaid Billing and Policy Manual, CHOICES Waiver, p. 10, (Feb. 2024), (Accessed Jul. 2024).
Pregnancy Program Providers
Pregnancy Program providers agree to provide for reasonable and adequate hours of operation and make available 24-hour, 7 days per week access by telephone for information, referral, and treatment needs during non-office hours. In addition, they agree to provide services via audio-only or telemedicine modalities if appropriate.
SOURCE: SD Medicaid Billing and Policy Manual, Pregnancy Program, p. 8, (Aug. 2024), (Accessed Jul. 2024).
ELIGIBLE PROVIDERS
In order to receive payment, all eligible servicing and billing provider’s National Provider Identifiers (NPI) must be enrolled with South Dakota Medicaid. Servicing providers acting as a locum tenens provider must enroll in South Dakota Medicaid and be listed on the claim form. Please refer to the provider enrollment chart for additional details on enrollment eligibility and supporting documentation requirements.
South Dakota Medicaid has a streamlined enrollment process for eligible ordering, referring, and attending providers that may require no action on the part of the provider as submission of claims constitutes agreement to the South Dakota Medicaid Provider Agreement.
Distant site locations must be in the United States. The physician or practitioner at the distant site must be licensed to provide the service in both the state of the originating site and state of the distant site. Services should be provided at a location consistent with any applicable laws or regulations regarding where services may be provided. The distant site and the originating site cannot be the same clinic/facility location. Unless prohibited by law or regulation the distant site location may be a provider’s home. South Dakota Medicaid does not require the distant site location be listed on their provider enrollment record. All services provided via telemedicine at a distant site must be billed with the GT modifier in the first modifier position to indicate the service was provided via telemedicine.
The following providers can provide services via telemedicine at a distant site:
- Audiologists
- Behavior Analyst
- Board-Certified Assistant Behavior Analyst (BCaBA)
- Certified Nurse Anesthetist
- Certified Social Worker – PIP
- Certified Social Worker – PIP Candidate
- Clinical Nurse Specialists
- Community Health Worker (CHW)
- Community Mental Health Centers
- Dentists
- Diabetes Education Program
- Dieticians
- Federally Qualified Health Center (FQHC)
- Indian Health Services (IHS) Clinics
- Licensed Marriage and Family Therapist
- Licensed Professional Counselor – MH
- Licensed Professional Counselor – working toward MH designation
- Nurse-midwife
- Nurse Practitioners
- Nutritionists
- Occupational Therapists
- Physical Therapists
- Physicians
- Physician Assistants
- Podiatrists
- Psychologist
- Radiologist
- Registered Behavior Technician (RBT)
- Rural Health Clinic (RHC)
- Speech Language Pathologists
- Substance Use Disorder Agencies
- Tribal 638 facilities
Telemedicine provided at a distant site must be billed with the GT modifier in the first modifier position to indicate the service was provided via telemedicine/audio-only. Failure to comply with this requirement may lead to payment recoupment or other action as decided by South Dakota Medicaid.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 3-4 (Jul. 2024). (Accessed Jul. 2024).
Indian Health Services and Tribal 638 Providers
IHS clinics are eligible to serve as an originating site for telemedicine services. IHS/Tribal 638s may also provide distant site telemedicine services. An originating site is the physical location of the Medicaid recipient at the time the service is provided. A distant site is the physical location of the practitioner providing the service via telemedicine.
Telemedicine Services Outside the Four Walls: Per a CMS temporary exception to the “Four Walls” requirement, home-to-home telemedicine services are permitted. This exception is in place until February 11, 2025. Under this exception, the IHS servicing provider and the recipient may be outside the four walls of a clinic. In order to bill for distant site telemedicine services at the encounter rate after February 11, 2025, the practitioner must be located at the IHS/Tribal 638 clinic (within the four walls).
Please refer to the Telemedicine Manual for additional information regarding telemedicine services.
IHS is eligible to serve as an originating site for telemedicine services and may also provide distant site telemedicine services.
- An originating site is the physical location of the Medicaid recipient at the time the service is provided.
- A distant site is the physical location of the practitioner providing the service via telemedicine.
Please refer to the Telemedicine manual for additional information.
Any services rendered by a contracted provider are reimbursed through their contract with IHS and may not be billed directly to Medicaid.
“Encounter,” a face-to-face or telemedicine contact between a health care professional and a Medicaid recipient for the provision of Medicaid or CHIP services through an IHS or Tribal 638 facility within a 24-hour period ending at midnight.
Telemedicine Distant Site Claim – If IHS or a Tribal 638 is providing distant site telemedicine services, the services should be billed on the applicable claim form for the service. For services billed on a CMS 1500 or 837P, the provider should include the GT modifier. For claims billed on a UB-04 or 837I, the following information should be entered in the applicable locator on a UB-04 claim or its equivalent on an electronic claim:
- Locator 42 – Enter appropriate Rev Code (example: 450 for outpatient)
- Locator 43 – Enter the appropriate description of the Rev Code
- Locator 44 – Enter one of the allowable HCPCS procedures codes listed in the Telemedicine
Services Manual and include the GT modifier.
SOURCE: SD Medicaid Billing and Policy Manual: IHS and Tribal 638 Providers, p. 5 & 12-13 & 14, (May 2024), (Accessed Jul. 2024).
ELIGIBLE SITES
South Dakota Medicaid covers telemedicine services even if the recipient and the provider are located in the same community. The decision of whether it is appropriate to deliver the service via telemedicine should be determined by the provider and the recipient.
Telemedicine originating sites for services provided via telemedicine include any site in the U.S. where the patient is at the time of the telemedicine service, including a person’s home. Originating sites listed below are eligible to receive a facility fee for each completed telemedicine transaction for a covered distant site telemedicine service. Sites not listed may also serve as an originating site but are not eligible for a facility fee reimbursement. Originating sites are not reimbursed for any additional costs associated with equipment, technicians, technology, or personnel utilized in the performance of the telemedicine service. The originating site fee is not reimbursable for audio-only services and should not be billed for these services. An originating site fee also is not reimbursable if the service could be provided onsite at the originating site, but the service is being provided via telemedicine solely due to patient preference to see a provider that is not located at the originating site.
Originating sites must be an enrolled provider to be reimbursed by South Dakota Medicaid. The following providers are eligible to be reimbursed a facility fee for serving as an originating site:
- Office of a physician or practitioner;
- Outpatient Hospital;
- Inpatient Hospital
- Critical Access Hospital;
- Rural Health Clinic (RHC);
- Federally Qualified Health Center (FQHC);
- Indian Health Service Clinic;
- A Hospital-Based or Critical Access Hospital-Based Renal Dialysis Center
- Community Mental Health Center (CMHC);
- Substance Use Disorder Agency;
- Nursing Facilities; and
- Schools
For distant site services billed on a CMS 1500 or 837P providers must bill;
- “02” for telemedicine services provided other than in patient’s home;
- “10” for telemedicine services provided in the patient’s home; or
- “77” for audio-only services.
[POS information listed in several provider manuals.]
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Jul. 2024). (Accessed Jul. 2024).
02 and 10 telemedicine POS Codes listed in several Claims Instructions documents.
SOURCE: SD Medicaid, Provider Manuals, Claims Instructions, & CMS 1500 Claims Instructions, (Accessed Jul. 2024).
FQHC/RHCs
FQHC/RHCs are eligible to serve as an originating site for telemedicine services and may also provide distant site telemedicine services. An originating site is the physical location of the Medicaid recipient at the time the service is provided.
Reimbursement for the telemedicine facility fee is limited to the amount listed on the Physician Services fee schedule.
A claim for a telemedicine originating site fee should be billed under the FQHC/RHC’s NPI. As indicated above, payment is limited to the fee schedule amount.
SOURCE: SD Medicaid Billing and Policy Manual: FQHC and RHC Services, (Jun. 2024) (Accessed Jul. 2024).
Indian Health Services and Tribal 638 Providers
IHS clinics are eligible to serve as an originating site for telemedicine services. IHS/Tribal 638s may also provide distant site telemedicine services. An originating site is the physical location of the Medicaid recipient at the time the service is provided.
IHS is eligible to serve as an originating site for telemedicine services and may also provide distant site telemedicine services.
- An originating site is the physical location of the Medicaid recipient at the time the service is provided.
- A distant site is the physical location of the practitioner providing the service via telemedicine.
Please refer to the Telemedicine manual for additional information.
Telemedicine Services Outside the Four Walls: Per a CMS temporary exception to the “Four Walls” requirement, home-to-home telemedicine services are permitted. This exception is in place until February 11, 2025. Under this exception, the IHS servicing provider and the recipient may be outside the four walls of a clinic. In order to bill for distant site telemedicine services at the encounter rate after February 11, 2025, the practitioner must be located at the IHS/Tribal 638 clinic (within the four walls). Please refer to the Telemedicine Manual for additional information regarding telemedicine services.
Any services rendered by a contracted provider are reimbursed through their contract with IHS and may not be billed directly to Medicaid.
If IHS is an originating site for a telemedicine service, the originating site fee should be billed on the applicable claim form for the service. For services billed on a CMS 1500 or 837P, IHS should bill for the originating site fee using HCPCS code Q3014. For claims billed on a UB-04 or 837I, the following information should be entered in the applicable locator or its equivalent on an electronic claim:
- Locator 42 – Rev Code 780
- Locator 43 – Telemedicine
- Locator 44 – Q3014
SOURCE: SD Medicaid Billing and Policy Manual: IHS and Tribal 638 Providers, p. 5, 13 (May 2024), (Accessed Jul. 2024).
GEOGRAPHIC LIMITS
South Dakota Medicaid covers telemedicine services even if the recipient and the provider are located in the same community. The decision of whether it is appropriate to deliver the service via telemedicine should be determined by the provider and the recipient.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 4 (Jul. 2024), (Accessed Jul. 2024).
FACILITY/TRANSMISSION FEE
Originating sites must be an enrolled provider to be reimbursed by South Dakota Medicaid. The following providers are eligible to be reimbursed a facility fee for serving as an originating site:
- Office of a physician or practitioner;
- Outpatient Hospital;
- Critical Access Hospital;
- Rural Health Clinic (RHC);
- Federally Qualified Health Center (FQHC);
- Indian Health Service Clinic;
- Community Mental Health Center (CMHC);
- Substance Use Disorder Agency;
- Nursing Facilities; and
- Schools
Originating sites listed in the eligible provider section are eligible to receive a facility fee for each completed telemedicine transaction for a covered distant site telemedicine service. Sites not listed may also serve as an originating site but are not eligible for a facility fee reimbursement. Originating sites are not reimbursed for any additional costs associated with equipment, technicians, technology, or personnel utilized in the performance of the telemedicine service. The originating site fee is not reimbursable for audio-only services and should not be billed for these services. An originating site fee also is not reimbursable if the service could be provided onsite at the originating site, but the service is being provided via telemedicine solely due to patient preference to see a provider that is not located at the originating site.
During the public health emergency, South Dakota Medicaid followed Medicare’s billing guidance allowing providers to bill the originating site fee if a hospital received approval to make a recipient’s home a “hospital location” known to and approved by Medicare. Effective May 11, 2023, providers will no longer be allowed make a recipient’s home a “hospital location” for the purpose of billing an originating site fee.
The maximum rate for originating site facility fee is listed on the physician fee schedule under procedure code Q3014. The facility fee is reimbursed on a fee for service basis including for providers paid at an encounter rate or other methodology. providers. There is no additional reimbursement for equipment, technicians, technology, or personnel utilized in the performance of telemedicine services. The originating site fee is not reimbursable for audio-only services and should not be billed for these services.
An originating site eligible for reimbursement must bill for the service using the HCPCS code Q3014 for CMS 1500 Claims or Revenue code 780 for UB-04 Claims. For group services with multiple recipients in the same originating site location, only one originating site fee is billable per physical location of the recipients. For Division of Behavioral Health block grant contract providers, the originating site fee should only be billed to Medicaid if the group includes both Medicaid recipients and individuals ineligible for Medicaid.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Jul. 2024). (Accessed Jul. 2024).
Skilled Nursing Facility and Nursing Facility Services
The telemedicine originating site fee is reimbursed at the lesser of the provider’s usual and customary charge and the fee for HCPCS code Q3014 listed on the Physician Services Fee Schedule.
The telemedicine originating site fee must be billed using revenue code 780. Refer to the Telemedicine manual for additional information regarding the telemedicine originating site fee.
SOURCE:SD Medicaid Billing and Policy Manual: Skilled Nursing Facility and Nursing Facility Services, p. 10-11, (Dec. 2023), (Accessed Jul. 2024).
Teledentistry
“Originating site”, physical location of the Medicaid recipient at the time the synchronous teledentistry service is provided.
An originating site is the physical location of the patient at the time a synchronous (live, two-way interaction between a patient and a provider using audiovisual telecommunications technology) teledentistry service is provided. A distant site is the physical location of the practitioner providing the service via synchronous teledentistry.
Enrolled dental providers, such as a dental office, FQHC/RHC, or IHS facility, are eligible to receive an originating site facility fee for acting as an originating site if the service being provided from the distant site is a covered teledentistry service. Other sites not listed may also serve as an originating site but are not eligible for an originating site facility fee reimbursement. Asynchronous services are not eligible for an originating site fee.
The maximum rate for originating site facility fee is listed on the physician fee schedule under procedure code Q3014. The facility fee is reimbursed on a fee for service basis for eligible encounter-based providers. There is no additional reimbursement for equipment, technicians, technology, or personnel utilized during services provided via teledentistry.
The originating site must submit a CMS 1500 or 837P claim to South Dakota Medicaid. For more information on originating sites please refer to the Telemedicine manual. Originating site are not reimbursed for any additional costs associated with equipment, technicians, technology, or personnel utilized in the performance of the teledentistry service. For more information on originating sites please refer to the Telemedicine manual.
SOURCE: SD Medicaid Billing and Policy Manual, Teledentistry Services, p. 4-6, (Jun. 2023), (Accessed Jul. 2024).
FQHC/RHC
Reimbursement for the telemedicine facility fee is limited to the amount listed on the Physician Services fee schedule.
A claim for a telemedicine originating site fee should be billed under the FQHC/RHC’s NPI. As indicated above, payment is limited to the fee schedule amount.
SOURCE: SD Medicaid Billing and Policy Manual: FQHC and RHC Services, p. 8 & 10 (Jun. 2024). (Accessed Jul. 2023).
School District Services
Q3014: Telehealth Originating Site Fee – For OT, PT, SLP, and psychology telehealth services only.
The telehealth originating site fee (Q3014) is not a time-based code. Providers should refer to the Telemedicine manual for additional billing guidance.
SOURCE: SD Medicaid and Policy Manual: School Districts, pg. 4 & 7 (Aug. 2024), (Accessed Jul. 2024).
Last updated 07/23/2024
Remote Patient Monitoring
POLICY
Effective October 1, 2023, South Dakota Medicaid added permanent coverage of remote patient monitoring of physiologic functions when medically necessary for recipients with acute or chronic conditions when ordered and billed by providers who are eligible to bill Medicaid for E/M services. Certain criteria must be met (see below).
See table on page 7-8 for eligible codes.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Jul. 2024) (Accessed Jul. 2024).
The Office of Adult Services and Aging
“Telehealth services,” a home based health monitoring system used to collect and transmit an individual’s clinical data for monitoring and interpretation.
SOURCE: SD Regulation 67:40:19:01(21) (Accessed Jul. 2024).
Home Health
For the initial order for home health services, a physician or other licensed practitioner must document a face-to-face encounter related to the primary reason the beneficiary requires the services. The encounter may occur through telemedicine. The encounter must occur within the 90 days before or 30 days after the start of the services
SOURCE: SD Medicaid Billing and Policy Manual: Home Health Services, p. 2 (Feb. 2024). (Accessed Jul. 2024).
Continuous Glucose Monitoring
South Dakota Medicaid covers continuous 72-hour glucose monitoring provided by an endocrinologist or an advanced practice provider working with an endocrinologist through the endocrinologist’s office no more than twice annually with a prior authorization.
SOURCE: SD Medicaid Billing and Policy Manual: Physician Services, p. 9 (Apr. 2024), (Accessed Jul. 2024).
CONDITIONS
The recipient must be diagnosed with at least one of the following conditions:
- Asthma
- Congestive Heart Failure
- Cardiac monitoring
- Hypertension or Hypotension
- Chronic Obstructive Pulmonary Disease
- Diabetes
- Gestational Diabetes
- COVID-19 post infection monitoring
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, pg. 6 (Jul. 2024) (Accessed Jul. 2024).
PROVIDER LIMITATIONS
Only a physician, physician assistant, nurse practitioner, or certified nurse midwife are allowed to order RPM and bill for the services.
FQHC/RHC
FQHC/RHC providers may bill for these services on a fee for service basis using their non-Prospective Payment System (PPS) NPI if the service is ordered by one of the allowable practitioner types.
IHS and Tribal 638
IHS and Tribal 638 facilities can bill the encounter rate for remote patient monitoring CPT codes 99091, 99457, and 99458 as long as these services meet the definition of an encounter and are in accordance with the “Four Walls” requirement under 42 CFR 440.90 as provided in the IHS and Tribal 638 Facilities manual.
School District Services
School district providers may provide physical and occupational therapy via telemedicine using CPT code 97799 for physical therapy and CPT code 97139 for occupational therapy. Speech-language pathology services continue to be allowed when provided via telemedicine and should be billed using CPT code 92507. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter.
Psychology services may also be provided via telemedicine or real time, two-way audio-only using CPT code 90899. Audio-only services must be provided in accordance with the independent mental health practitioner coverage criteria stated in this manual.
Please refer to the School District Services manual for additional coverage information.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Jul. 2024) (Accessed Jul. 2024).
OTHER RESTRICTIONS
The recipient must be cognitively capable of operating the remote monitoring equipment or must be assisted by a caregiver capable of operating the equipment.
The recipient’s condition must be unmanaged or require frequent and on-going monitoring during a period where:
- The recipient is newly diagnosed with the condition in the last 6 months and is learning to manage the condition;
- The recipient has a chronic condition that has become difficult to manage in the last 6 months; or
- The recipient has had 2 or more episodes that required either emergency department care, hospitalization, or emergency intervention in the last 6 months.
The medical device supplied to a recipient as part of RPM services must be a medical device as defined by Section 201(h) of the Federal Food, Drug, and Cosmetic Act, that the device must be reliable and valid, and that the data must be electronically (i.e., automatically) collected and transmitted rather than self-reported.
RPM is only allowed for established patients who are under the active care of a provider.
The provider must document the medical necessity of the service.
The provider must obtain consent from the recipient to furnish RPM services.
The provider must prescribe a care plan that denotes the need for remote monitoring and the impact on treatment and management of the recipient . The care plan must also address actions taken by the provider and/or care team to improve or address the recipient’s ability to self manage the condition including patient education.
Prior Authorization
The out-of-state prior authorization requirement does not apply if the recipient is located in South Dakota at the time of the service and the provider is located outside of the State. If the service otherwise requires a prior authorization, the provider is still required to obtain prior authorization prior to providing the service.
SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Jul. 2024), (Accessed Jul. 2024).
