South Dakota Medicaid Obstetrical Billing Guide: 2026 Rules and the 2027 Transition

South Dakota Medicaid updated its Obstetrical Services billing manual in September 2026, ahead of the AMA's January 1, 2027 maternity coding transition, and is giving providers flexibility now.  While global obstetric codes remain valid through December 31, 2026, providers may choose to report

• antepartum,
• delivery, and
• postpartum services

individually before the transition.

This guidance explains how South Dakota Medicaid will process these billing options and what providers should know when reporting maternity services in between billing options.

South Dakota Medicaid Provider Enrollment Requirements

According to South Dakota Medicaid, claims will only be paid if the NPI for all eligible providers for the services and all billable providers are enrolled in Medicaid. Additionally, Locum tenens providers need to be also enrolled and appear on the claim form.

South Dakota Medicaid makes enrollment easy for eligible ordering, referring, and attending providers. In most cases, these providers don't need to do anything extra, because submitting a claim automatically counts as accepting the South Dakota Medicaid Provider Agreement. 

Enrolled Providers

• Physicians
• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Nurse midwives

Eligible Recipients and Coverage Limits

Before providing any service, providers should check the patient's Medicaid ID card and confirm eligibility through the South Dakota Medicaid online portal. Coverage depends on the patient's program:

• Medicaid/CHIP Full Coverage: All medically necessary services are covered, subject to the limits in the program guidelines.
• Unborn Children Prenatal Care Program (79): Coverage is limited to pregnancy-related services, including medical conditions that could put the mother's or baby's life at risk.

Covered Obstetrical Services and Limits

South Dakota Medicaid covers specific obstetrical services within established coverage limits. The following services and limits outline the obstetrical care that may be covered under the program.

General Coverage Requirements

Every service billed to South Dakota Medicaid must meet the basic requirements in the General Coverage Principles manual. Before a claim can be paid, make sure that:

• The provider is properly enrolled
• The service is medically necessary
• The patient is eligible for Medicaid
• Prior authorization is obtained, if required

The manual also covers non-discrimination rules that all providers must follow.

Reporting the Initial Prenatal Visit (CPT 0500F)

South Dakota Medicaid encourages providers to report the first prenatal visit. This helps Medicaid and the Department of Health reach pregnant patients with educational materials and case management support when needed. Medicaid also pays eligible providers for this reporting.

Here are the key billing rules for 0500F:

• Bill 0500F within 15 days of the initial prenatal visit.
• It can be billed only once per pregnancy.
• Add any other services provided on the same day to the claim as usual.
• If the patient wasn't eligible on the visit date but coverage is later backdated to include that date, 0500F can still be billed, as long as it is submitted before delivery.
• FQHCs, RHCs, and IHS facilities should list 0500F on the encounter claim. It will be paid at the fee-for-service rate in addition to the encounter payment.

Billing Flexibilities Before the 2027 CPT Code Changes

Global obstetric codes stay valid for dates of service through December 31, 2026. Since some pregnancies will continue into 2027, South Dakota Medicaid now lets providers start billing OB services individually before the global codes are retired. Here is how each part of care can be billed for dates of service through December 31, 2026:

• Antepartum care: Bill per visit using E/M codes (CPT 99202 to 99499) with pregnancy-related ICD-10-CM diagnosis codes and the TH modifier.
• Labor and delivery: Bill per delivery using delivery-only codes 59409, 59514, 59612, or 59620. These include immediate postpartum care on the day of delivery. Any other services must be billed separately.
• Postpartum care: Bill per visit using E/M codes (CPT 99202 to 99499) with diagnosis code Z39.2 and the TH modifier.

Providers can still use global OB codes (59400, 59510, 59610, 59618) in 2026, but only when the entire episode of care falls within 2026. Keep these key rules in mind:

• If any part of the pregnancy care crosses into 2027, global codes cannot be used for any part of that episode. All services must be billed individually.
• Once you choose individual billing for a pregnancy, use it for the entire episode. Global and individual billing cannot be mixed.
• If, for any reason, a delivery is inadvertently shipped in 2027, all global claims will be cancelled and submitted with individual codes during the statutory filing time.
• In shared or transferred care, each provider submits a bill only for services rendered by them.

For example: If a patient is due on December 28th 2026, delivery takes place on January 2nd 2027. All prenatal, delivery, and postpartum services are billed separately, no part of the episode is billed globally.

Global Obstetrics Billing Rules

South Dakota Medicaid allows a global OB code only when one provider, or providers within the same group practice, handle the complete pregnancy. That means at least 4 antepartum visits, the delivery, and postpartum care. Global services are billed with CPT 59400, 59510, 59610, or 59618, and the date of delivery is used as the date of service. When a global code is billed, antepartum care, delivery, and postpartum care cannot be submitted on separate claims.

The global period starts on the date of the visit where the pregnancy is confirmed and runs through the end of the postpartum period. For a vaginal delivery, this is 56 days after birth. For a cesarean delivery, it is 90 days after birth.

Not every pregnancy fits the global package. Providers should itemize obstetric services instead when:

• The patient transfers into or out of the physician or group practice
• The patient is referred to another physician during the pregnancy
• The delivery is performed by a physician or health care professional outside the practice
• The pregnancy ends in termination or miscarriage
• The patient changes insurers and the change prevents billing all services under the global code

Billing Rules for FQHC, RHC, IHS, and Tribal 638 Providers

FQHCs, RHCs, IHS, and Tribal 638 providers that deliver prenatal or postpartum care must itemize their billing rather than use a global code. Prenatal visits are billed with the applicable E/M code and a pregnancy-related diagnosis code, and South Dakota Medicaid requires the TH modifier on these prenatal E/M codes. The only exception is the first visit where the pregnancy is confirmed, which should not carry the TH modifier. Postpartum visits are billed with CPT 59430.

Duplicate billing is not allowed. For example, a provider cannot bill prenatal visits with E/M codes and then also bill a global delivery code for the same pregnancy. If a third-party payer requires the services under a different code, the provider should note this on the explanation of benefits submitted with the claim, but the claim to Medicaid must still use the applicable E/M code.

Services Included in the Global OB Package

The following services are combined and not billable independently if a global code is used: 

• All routine prenatal visits until delivery
• Initial and follow-up history and physical exams
• Recording weight, blood pressure, and fetal heart tones
• Routine chemical urinalysis (CPT 81000 and 81002)
• Hospital admission, including history and physical
• Inpatient E/M services within 24 hours of delivery
• Management of uncomplicated labor
• Vaginal or cesarean delivery of a single baby
• Delivery of the placenta (CPT 59414)
• IV oxytocin administration or induction (CPT 96365 to 96367)
• Cervical dilator insertion on the same date as delivery (CPT 59200)
• Repair of first or second degree lacerations
• Simple cerclage removal without anesthesia
• Uncomplicated inpatient visits after delivery
• Routine outpatient E/M visits within 6 weeks of delivery
• Postpartum care only (CPT 59430)
• Education on breastfeeding, lactation, and basic newborn care

Third or fourth degree lacerations are not treated as routine. Per ACOG, these should be reported by adding modifier 22 to the global OB code or the delivery-only code.

Services Excluded From the Global OB Package

Some services go beyond routine pregnancy care and can be billed separately when medically necessary:

• The initial E/M visit to diagnose pregnancy, if the antepartum record is not started at that visit. This visit is supported with ICD-10-CM code Z32.01 (encounter for pregnancy test, result positive).
• Laboratory tests, except routine chemical urinalysis
• Maternal or fetal ultrasound procedures (CPT 76801, 76802, 76805, 76810 to 76817, 76820, 76821, and 76825 to 76828)
• Amniocentesis (CPT 59000 or 59001)
• Amnioinfusion (CPT 59070)
• Chorionic villus sampling (CPT 59015)
• Fetal contraction stress test (CPT 59020)
• Fetal non-stress test (CPT 59025)
• External cephalic version (CPT 59412)
• Cervical dilator insertion more than 24 hours before delivery (CPT 59200)
• E/M visits for conditions unrelated to pregnancy, such as bronchitis, asthma, or a urinary tract infection, supported by the correct diagnosis
• Additional E/M visits for complications or high-risk monitoring beyond the typical 13 antepartum visits, reported after delivery with modifier 25
• Inpatient E/M services provided more than 24 hours before delivery
• Management of surgical problems during pregnancy, such as appendicitis, ruptured uterus, or cholecystectomy

Long-acting reversible contraceptives (LARC) are also reimbursable when placed immediately after delivery or before hospital discharge. The South Dakota Medicaid Family Planning manual covers these in more detail.

Billing for High-Risk Pregnancies and Complications

A typical pregnancy includes about 13 antepartum visits, but high-risk patients or those with complications often need more. These extra visits are not considered routine, so they can be billed in addition to global codes 59400, 59510, 59610, or 59618.

To be reimbursed separately, these visits must meet three conditions:

• They are submitted at the time of delivery, since the total number of antepartum visits can only be assessed then
• Modifier 25 is added to show the visit is significant and separate from routine prenatal care
• The claim includes an appropriate high-risk or complication diagnosis code

Antepartum Care Only Billing

Antepartum care only codes are used when the provider, or providers within the same group, will not be billing all three parts of global obstetric care: 4 or more antepartum visits, the delivery, and postpartum care. If the antepartum record is not started at the visit where the pregnancy is confirmed, that first visit can be billed separately with an initial E/M code.

When antepartum services do not qualify for a global code, the number of visits decides how they are billed:

• 3 or fewer visits: Bill each visit with the appropriate E/M code.
• 4 to 6 visits: Bill CPT 59425. Do not bill the first visits with E/M codes, because they are already included in 59425.
• 7 or more visits: Bill CPT 59426 only. Do not bill 59425 along with it, since all earlier visits are already included in 59426.

Delivery Only Billing

The delivery period begins on the date the patient is admitted to the hospital for delivery and ends on the date she is discharged. All hospital care related to the delivery is part of the delivery charge, not postpartum care. For a cesarean delivery, the delivery only payment covers both the surgery and the post-surgical care. Bill this service with the applicable delivery only code from the CPT manual.

If a provider performs both antepartum care and the delivery but does not provide postpartum care, bill the applicable antepartum only code and delivery only code separately.

Delivery and Postpartum Care Billing

When a provider performs the delivery and postpartum care but did not provide at least 4 antepartum visits, bill the matching delivery and postpartum care code:

• Vaginal delivery with postpartum care: CPT 59410
• Cesarean delivery with postpartum care: CPT 59515
• VBAC with postpartum care: CPT 59614
• Cesarean after attempted VBAC with postpartum care: CPT 59622

Postpartum Care Only Billing

Postpartum care begins after the patient is discharged from the delivery hospital stay and continues through the postpartum period, which is 56 days for a vaginal delivery and 90 days for a cesarean. Postpartum care only must be billed with CPT 59430.

Patients covered under the Unborn Children Prenatal Care Program (Aid Category 79) follow a different rule. Their Medicaid eligibility ends after delivery, so CPT 59430 is not covered for them. Instead, postpartum care is covered only when billed with a delivery and postpartum care code (59410, 59515, 59614, or 59622), using the date of delivery as the date of service.

Postpartum Billing Flexibility Before the 2027 Code Changes

Ahead of the January 1, 2027 transition, South Dakota Medicaid allows providers to bill postpartum services individually. Each visit can be billed per encounter with E/M codes (CPT 99202 to 99499), using diagnosis code Z39.2 for routine postpartum follow-up and the TH modifier on postpartum E/M codes.

Billing for Multiple Deliveries

Twin and multiple births are billed based on how each baby is delivered:

• Both babies delivered vaginally: Bill Baby A with 59400 or 59610. Bill Baby B with 59409 or 59612 and add modifier 51.
• Both babies delivered by cesarean: Bill one code, 59510 or 59618, for Baby A and Baby B together. Add modifier 22 if the delivery was significantly more difficult because of the multiple gestation, and make sure the medical record supports it.
• One vaginal and one cesarean delivery: Bill Baby A with 59510 or 59618. Bill Baby B with 59409 or 59612 and add modifier 51.

Physician Standby Services (CPT 99360)

Physician standby is covered only when a physician must remain present for a prolonged period waiting for a newborn's birth during a cesarean or high-risk delivery. It is billed under the birthing mother, and the physician must be fully dedicated to that patient, without treating anyone else during the standby time. Here are the billing rules:

• Bill in 30-minute units it is with 1 unit equal to 30 minutes
• A maximum of 4 units (2 hours) can be billed per date
• Each additional unit requires a full 30 minutes of standby
• Standby time under 30 minutes in total cannot be billed
• 99360 can be billed along with 99440 and 99465

Providers must keep documentation showing why the physician's immediate presence was medically necessary, a detailed record of the tasks performed, and the actual time spent with the patient.

Genetic Screenings

Genetic tests included in the Newborn Metabolic Screening Program, as required by the South Dakota Department of Health, are covered without prior authorization. Diagnostic genetic testing is covered only when the results will affect the patient's treatment decisions. Noninvasive prenatal testing (CPT 81420 or 81507) requires prior authorization, as do many other genetic tests. The Laboratory and Pathology Services manual has more details.

Depression Screenings

South Dakota Medicaid covers up to six depression screenings (CPT 96127). These codes are within a 12-month period. Maternal depression screening is also covered at 1, 2, 4, and 6 months postpartum when performed along with the infant's well-child visit. Providers are encouraged to screen birthing mothers who have a Medicaid-eligible child under age 1. Key billing points:

• Bill CPT 96161 for maternal depression screening done with a standardized screening tool
• Use the child's South Dakota Medicaid recipient ID number on the claim
• Refer the mother for follow-up treatment when needed

Obstetrical Ultrasound Coverage

South Dakota Medicaid covers ultrasounds during pregnancy when they are medically necessary for one or more of these reasons:

• Confirming the date of conception or gestational age
• A standard anatomy scan to check fetal development and screen for major congenital anomalies
• A difference between the baby's size and expected fetal age
• Early diagnosis of an ectopic or molar pregnancy
• Fetal postmaturity syndrome
• Guiding an amniocentesis
• Locating the placenta when there is abnormal vaginal bleeding (placenta previa)
• Polyhydramnios or oligohydramnios
• A suspected congenital anomaly
• Suspected multiple births
• Any other condition directly related to diagnosing or treating the mother or baby

An E/M visit on the same day as an obstetrical ultrasound is paid separately only when it is a distinct service and is billed with modifier 25.

Ultrasounds done only to find out the baby's gender or to take baby pictures are not covered.

Coverage for Pregnancy Loss

South Dakota Medicaid covers care related to a pregnancy that does not end in a live birth, as well as compassionate or palliative care for a baby born from a non-viable pregnancy. Covered services include:

• Services and supplies related to miscarriage, stillbirth, or a non-viable pregnancy, such as a molar pregnancy, ectopic pregnancy, or fetal death in utero
• Postpartum services, including behavioral health support

Prenatal Vitamins, Iron, and Aspirin

Several medications and supplements are covered for pregnant patients with a prescription:

• Prenatal vitamins: Covered with a prescription.
• Iron supplements: Covered under the pharmacy benefit with a prescription.
• Low-dose aspirin (81 mg per day): Covered under the pharmacy benefit with a prescription for patients at high risk for preeclampsia, starting after 12 weeks of pregnancy. This follows the USPSTF A and B grade preventive recommendations.

For more on over-the-counter drug coverage, refer to the Pharmacy Services manual.

Doula Services

South Dakota Medicaid covers doula services as a preventive service under 42 CFR 440.130. Because federal rules require preventive services to be recommended by a licensed practitioner, a doula's services must be referred by a physician, physician assistant, certified nurse practitioner, or certified nurse midwife. Key referral rules:

• The patient must have had a face-to-face or telemedicine visit with the referring provider within the last 90 days.
• Patients enrolled in a Medicaid care management program (BabyReady, Primary Care Provider Program, or Care Connect Program) must get the referral from their designated provider.
• At the provider's discretion, the referral can cover services that started up to 60 days before the referral date.
• Getting the referral as early as possible helps avoid services that cannot be reimbursed.

Pregnancy Support Programs

There are a few programs in South Dakota available to support pregnant patients beyond the scope of routine medical care. Providers can educate patients about these programs to ensure they are directed to the appropriate resources and, in some instances, receive extra reimbursement. 

BabyReady Care Management Program

The BabyReady Program aims to improve maternal health outcomes through better care coordination, care that follows established standards, and fewer barriers to access. Participating providers are responsible for coordinating care for the patients on their caseload. In return, they receive:

• Standard reimbursement for services
• A monthly case management fee for care coordination
• Enhanced reimbursement for meeting prenatal and postpartum care program goals

Providers interested in joining can find more details in the BabyReady manual.

Bright Start Program

Bright Start is a home visiting program for expectant, first-time mothers enrolled in Medicaid. Each eligible mother is paired with a free personal nurse who supports her from pregnancy until her child's second birthday. The program focuses on healthier pregnancies, better child health and development, and greater family self-sufficiency.

Pregnancy Care Program

The Department of Health's Pregnancy Care Program is open to pregnant women of all income levels. It provides a Pregnancy Care nurse at no cost, who can answer questions and offer support from the start of pregnancy. The program also offers:

• Check-ins with a registered nurse for pregnancy education
• Postpartum support for mom and baby after delivery
• Guidance on breastfeeding, nutrition, safe sleep, and other healthy pregnancy practices

Providers or patients can call or visit a local Public Health Nursing Office to connect with a Pregnancy Care nurse.

Non-Covered Services

For the general list of services South Dakota Medicaid does not cover, refer to ARSD 67:16:01:08 or the General Coverage Principles manual.

Documentation Requirements

Providers must keep clear, readable medical and financial records that fully support every service billed to South Dakota Medicaid. These records must be kept for at least 6 years after the last date a claim was paid or denied. The Documentation and Record Keeping manual lists additional requirements.

Reimbursement and Claim Instructions

Timely Filing

South Dakota Medicaid must receive a completed claim within 6 months after the month the service was provided. Reconsideration requests are reviewed only if they arrive within the timely filing period or within 3 months of the claim denial date. In certain situations, South Dakota Medicaid may waive or extend these time limits. See the General Claim Guidance manual for details.

Third-Party Liability

Many Medicaid patients have other health coverage, and South Dakota Medicaid is generally the payer of last resort. Providers must check for other payment sources first and follow the Medicare Crossover or Third-Party Liability billing manuals when they apply.

Primary insurers often limit which codes can be used on a claim. When the primary insurance requires a code that South Dakota Medicaid does not use, bill Medicaid with the E/M code and note "primary insurance requires a different code" on the EOB so the claim can be considered for payment.

How Reimbursement Is Calculated

Claims for physician services must be submitted at the provider's usual and customary charge. Payment is the lower of that charge or the amount on South Dakota Medicaid's Physician Services fee schedule. For procedures without an established fee:

• Non-laboratory procedures, including injections and immunizations: Paid at 40 percent of the usual and customary charge
• Laboratory procedures: Paid at 60 percent of the usual and customary charge

Procedure Code Modifiers

A modifier is a small code added to a procedure code to explain something special about the service. Some modifiers change how much the provider gets paid. For example:

• Modifier 50 means the procedure was done on both sides of the body (bilateral), so payment goes up to 150%.
• Modifier 80 means the provider was an assistant surgeon, so payment goes down to 20%.

When both modifiers are used together, South Dakota Medicaid applies them one after the other:

• Step 1: Start with the fee: $236.60
• Step 2: Apply modifier 50 (150%): $236.60 x 1.5 = $354.90
• Step 3: Apply modifier 80 (20%): $354.90 x 0.2 = $70.98

So the final payment is $70.98.

In simple words, each modifier adjusts the payment in turn, and the final amount reflects all of them combined.

If you want this in the article, here's a simpler version of the section:

Claim Submission Rules

Professional services, both inpatient and outpatient, must be billed on a CMS 1500 claim form or an 837P electronic claim. Detailed claim form instructions are available on the South Dakota Medicaid website. Keep these rules in mind:

• A claim for a physician or licensed practitioner must be for services they personally provided, or that were provided by an employee under their direct supervision.
• Claims for services by a clinical nurse specialist, certified nurse midwife, nurse practitioner, or physician assistant must use that practitioner's own provider ID number.
• These claims cannot be submitted under the supervising physician's provider ID.

With the 2027 maternity coding changes approaching, South Dakota OB practices need to track billing methods, modifiers, and program requirements carefully to avoid denials. BillingFreedom helps OB/GYN practices manage South Dakota Medicaid billing, from global and individual maternity coding to enrollment and program-based reimbursement, so claims are paid correctly and on time. For a review of your South Dakota maternity billing workflow, email info@billingfreedom.com 

Quick Answer: D&C After Pregnancy Loss in the Unborn Children Program

South Dakota Medicaid covers a medically necessary D&C and follow-up care for a patient who miscarries while covered under the Unborn Children Prenatal Care Program. Claims for a D&C or follow-up care more than 30 days after the pregnancy loss must be submitted with medical records for review and may not be covered.