CHAPTER 47:03:05
MEDICAL FEE SCHEDULES
Section
47:03:05:01 Definitions.
47:03:05:02 Incorporation of Relative Values for Physicians.
47:03:05:02.01 Incorporation of Relative Values for Dentists.
47:03:05:03 and 47:03:05:04 Repealed.
47:03:05:05 Reimbursement criteria.
47:03:05:06 Dispute resolution.
47:03:05:07 Mediation.
47:03:05:08 Repealed.
47:03:05:09 Reimbursement for copies.
47:03:05:10 Repealed.
47:03:05:10.01 Reimbursement for anesthesia services.
47:03:05:11 Repealed.
47:03:05:12 Reimbursement for other medical services.
47:03:05:13 Reimbursement for dental services
47:03:05:14 Reimbursement for drugs.
Appendix A Physician Fee Schedule, repealed, 38 SDR 105, effective December 12, 2011.
Appendix B Facilities Subject to 20% Reduction.
Appendix C Supplemental Anesthesia Schedule, repealed, 38 SDR 105, effective December 12, 2011.
DEPARTMENT
OF LABOR
WORKERS'
COMPENSATION
PHYSICIAN
FEE SCHEDULE
Chapter
47:03:05
APPENDIX
A
SEE:
§ 47:03:05:10
(Repealed)
Source:
23 SDR 23, effective August 22, 1996; 24 SDR 7, effective July 30, 1997; 25 SDR
72, effective November 22, 1998; 27 SDR 1, effective July 19, 2000; 29 SDR 55,
effective October 28, 2002; 29 SDR 182, effective July 6, 2003; 31 SDR 220,
effective July 12, 2005; 32 SDR 209, effective June 14, 2006; 33 SDR 66,
effective October 24, 2006; 33 SDR 226, effective June 27, 2007; 34 SDR 310,
effective June 19, 2008; repealed, 38 SDR 105, effective December 12, 2011.
DEPARTMENT OF LABOR AND REGULATION
WORKERS' COMPENSATION
FACILITIES SUBJECT TO 20% REDUCTION
Chapter 47:03:05
APPENDIX B
SEE: § 47:03:05:12
Source: 23 SDR 23, effective August 22, 1996; 25 SDR 72, effective November 22, 1998; 29 SDR 55, effective October 28, 2002; 32 SDR 209, effective June 14, 2006; 34 SDR 209, effective February 14, 2008; 39 SDR 219, effective June 26, 2013.
FACILITIES SUBJECT TO 20% REDUCTION
Avera Heart Hospital
Avera McKennan Hospital
Avera Queen of Peace Hospital
Avera Sacred Heart Hospital
Avera St. Luke's Hospital
Avera St. Mary's Hospital
Black Hills Surgical Hospital
Brookings Ambulatory Surgical Center
Brookings Hospital
Dakota Plains Surgical Center
Huron Regional Medical Center
Lewis and Clark Specialty Hospital
Mallard Point Surgical Center
Prairie Lakes Hospital
Prairie States Surgical Center
Rapid City Regional Hospital
Same Day Surgery Center
Sanford Aberdeen Medical Center
Sanford USD Medical Center
Sioux Falls Specialty Hospital
Sioux Falls Surgical Hospital
Siouxland Surgery Center
Yankton Medical Clinic Surgicenter
DEPARTMENT
OF LABOR
WORKERS'
COMPENSATION
SUPPLEMENTAL
ANESTHESIA SCHEDULE
Chapter
47:03:05
APPENDIX
C
SEE:
§ 47:03:05:01, 47:03:05:10.01
(Repealed)
Source: 33 SDR 226,
effective June 27, 2007; repealed, 38 SDR 105, effective December 12, 2011.
47:03:05:01. Definitions. Terms used in this chapter mean:
(1) "Anesthesia services," administration of any drug or combination of drugs with the purpose of creating sedation or analgesia;
(2) "Base unit value," the number value assigned to services in Relative Values for Physicians;
(3) "Dental services," the examination, diagnosis, treatment, planning, and care of conditions within the human oral cavity and its adjacent tissues and structures, for any disease, pain, deformity, deficiency, injury, or physical condition of the human tooth, teeth, alveolar process, gums, or jaw or adjacent or associated structures;
(4) "Department," the Department of Labor and Regulation;
(5) "Employee," an employee entitled to medical services, dental services, or treatment for a compensable injury or disability under SDCL 62-4-1;
(6) "Health care provider," a person or entity providing medical services, dental services, or treatment to an employee for a compensable injury or disability;
(7) "Insurer," an entity providing workers' compensation insurance, including self-insured employers;
(8) "Medical services" or "treatment," a procedure, operation, consultation, supply, or product provided for the purpose of curing or relieving an employee of the effects of a compensable injury or disability;
(9) "Medical fee schedule," the maximum allowable fee for medical services or treatment determined according to the procedures established in this chapter;
(10) "Physical status modifier unit value," the number value assigned to physical status modifiers for anesthesia services in Relative Values for Physicians;
(11) "Procedure code," a numerical code used to identify a specific medical service, article, or supply;
(12) "Professional services," examination of a patient, performance or supervision of a medical procedure, dental procedure, or laboratory test, interpretation or written report concerning an examination or laboratory test, consultation with referring physicians, or similar services;
(13) "Qualifying circumstances unit value," the number value assigned to qualifying circumstances for anesthesia services in Relative Values for Physicians;
(14) "Technical services," performance of laboratory or radiological diagnostic procedures;
(15) "Unit value," the number value assigned to a dental service in Relative Values for Dentists;
(16) "Usual and customary charges," charges or fees that prevail in the community regardless of payer source.
Source: 21 SDR 67, effective October 13, 1994; 23 SDR 23, August 22, 1996; 24 SDR 7, effective July 30, 1997; 25 SDR 72, effective November 22, 1998; 32 SDR 209, effective June 14, 2006; 33 SDR 226, effective June 27, 2007; 34 SDR 310, effective June 19, 2008; 38 SDR 105, effective December 12, 2011; 39 SDR 219, effective June 26, 2013; 42 SDR 177, effective June 28, 2016; 43 SDR 181, effective July 7, 2017; 44 SDR 185, effective June 25, 2018; 47 SDR 42, effective October 14, 2020.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
References: Relative Values for Dentists, 2009 edition, published by Relative Value Studies, Inc. Copies may be obtained from Relative Value Studies, Inc., 1675 Larimer Street, Suite 410, Denver, CO 80202; https://www.rvsdata.com/rvs-bin/order1a.cgi#oprvd. Cost: $70.
Relative Values for Physicians, Relative Value Studies, Inc., 2020, published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050, Chicago, IL 60680-9920. Cost: $329.95.
47:03:05:02. Incorporation of Relative Values for Physicians. Except as otherwise provided in this chapter, the definitions and procedures for determining reimbursement for medical services or treatment are those set forth in Relative Values for Physicians, Relative Value Studies, Inc.
Source: 21 SDR 67, effective October 13, 1994; 25 SDR 72, effective November 22, 1998; 29 SDR 55, effective October 28, 2002; 29 SDR 182, effective July 6, 2003; 31 SDR 220, effective July 12, 2005; 32 SDR 209, effective June 14, 2006; 33 SDR 226, effective June 27, 2007; 34 SDR 310, effective June 19, 2008; 38 SDR 105, effective December 12, 2011; 39 SDR 100, effective December 6, 2012; 39 SDR 219, effective June 26, 2013; 42 SDR 177, effective June 28, 2016; 43 SDR 181, effective July 7, 2017; 44 SDR 185, effective June 25, 2018; 47 SDR 42, effective October 14, 2020.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
Reference: Relative Values for Physicians, Relative Value Studies, Inc., 2020, published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050, Chicago, IL 60680-9920. Cost: $329.95.
47:03:05:02.01. Incorporation of Relative Values for Dentists. The definitions and procedures for determining reimbursement for dental services or treatment are those set forth in Relative Values for Dentists, 2024.
Source: 25 SDR 72, effective November 22, 1998; 31 SDR 220, effective July 12, 2005; 38 SDR 105, effective December 12, 2011; 51 SDR 54, effective November 12, 2024.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
Reference: Relative Values for Dentists, 2024 edition, published by Relative Value Studies, Inc. Copies may be obtained from Relative Value Studies, Inc., 12921 S. Vista Station Blvd., Ste 200, Draper, UT 84020. Available for order by telephone at 1-800-464-3649, option 1. Cost: $700 base cost, plus an additional $25 per user.
47:03:05:03. Determining reimbursement -- Conversion factors.Repealed.
Source: 21 SDR 67, effective October 13, 1994, and July 1, 1995; 21 SDR 225, effective July 5, 1995; repealed, 23 SDR 23, effective August 22, 1996.
47:03:05:04. Physical medicine.Repealed.
Source: 21 SDR 67, effective October 13, 1994; 21 SDR 225, effective July 5, 1995; repealed, 23 SDR 23, effective August 22, 1996.
47:03:05:05. Reimbursement criteria. To be reimbursed, the charge must be for reasonable and necessary services for the cure or relief of the effects of a compensable injury or disability. A health care provider is not entitled to payment from an insurer or employee for fees in excess of the maximum reimbursement allowed under this chapter.
Except as otherwise provided in this chapter, to determine the maximum reimbursement for services, the base unit value for a procedure code is multiplied by the following factors:
Procedure Code Factor
10000-69999 $100.80
70000-79999 $ 19.07
80000-89999 $ 15.28
90000-95906 $ 6.57
95907-95913 $ 8.39
95914-97150 $ 6.57
97161 $ 21.11
97162 $ 13.20
97163 $ 6.61
97164 $ 15.08
97165 $ 21.11
97166 $ 13.20
97167 $ 6.61
97168 $ 15.08
97169-99071 $ 6.57
99075 $ 14.37 1st hour, $1.78 each additional 15 min
99076-99199 $ 6.57
99201-99450 $ 8.00
99455-99456 $ 19.33 1st hour, $2.41 each additional 15 min
99460-99499 $ 8.00
99500-99607 $ 6.57
If a code is properly submitted for one of these services, but is not listed in Relative Values for Physicians, or the base unit value is RNE or BR, the reimbursement is 80% of the provider's charge.
Source: 21 SDR 67, effective October 13, 1994; 23 SDR 23, effective August 22, 1996; 38 SDR 105, effective December 12, 2011; 39 SDR 100, effective December 6, 2012; 39 SDR 219, effective June 26, 2013; 42 SDR 177, effective June 28, 2016; 43 SDR 181, effective July 7, 2017; 44 SDR 185, effective June 25, 2018; 47 SDR 42, effective October 14, 2020.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
Cross-Reference: Properly submitted medical bill, § 47:03:09:01.
Reference: Relative Values for Physicians, Relative Value Studies, Inc., 2020, published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050, Chicago, IL 60680-9920. Cost $329.95.
47:03:05:06. Dispute resolution. A person or entity aggrieved by the action of an insurer regarding medical fees must exhaust the dispute resolution procedure of the insurer before filing a petition or otherwise seeking relief from the department. If the aggrieved party has exhausted the dispute resolution procedure of the insurer or the insurer has failed to resolve a dispute within 30 calendar days after the dispute was submitted to the insurer, the party may petition the department for a hearing on the matter in dispute pursuant to SDCL chapter 1-26. The petition for a hearing must be mailed within 30 calendar days after written notice of the final decision of the insurer is mailed to the aggrieved party.
Source: 21 SDR 67, effective October 13, 1994.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:07. Mediation. When a petition for a hearing is filed under § 47:03:05:06, the Department may grant a request for mediation before conducting a hearing under SDCL chapter 1-26 on the matter if the department determines that a party will not be prejudiced substantially.
Source: 21 SDR 67, effective October 13, 1994.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:08. Reimbursement
for evaluation and management services. Repealed.
Source:
21 SDR 225, effective July 5, 1995; repealed, 38 SDR 105, effective December
12, 2011.
47:03:05:09. Reimbursement for copies. The maximum reimbursement for copies of provider records is ten dollars for the first ten pages, and thirty-three cents for each additional page.
Source: 21 SDR 225, effective July 5, 1995; 23 SDR 23, effective August 22, 1996.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:10. Reimbursement
for physician, technical, or professional services. Repealed.
Source:
23 SDR 23, effective August 22, 1996; 24 SDR 7, effective July 30, 1997;
repealed, 38 SDR 105, effective December 12, 2011.
47:03:05:10.01. Reimbursement for anesthesia services. The reimbursement for anesthesia services may not exceed the amount determined by adding the base unit value, the physical status modifier unit value, and the qualifying circumstances unit value, and multiplying the result by $40.28. An amount not to exceed $40.28 may be added for each additional fifteen minutes of anesthesia time. Any amount of anesthesia time that is less than fifteen minutes but at least five minutes may be rounded to the next fifteen minute increment.
Source: 24 SDR 7, effective July 30, 1997; 32 SDR 209, effective June 14, 2006; 42 SDR 177, effective June 28, 2016.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:11. Reimbursement
for professional or technical services rendered by a hospital or ambulatory
surgical center. Repealed.
Source:
23 SDR 23, effective August 22, 1996; 24 SDR 7, effective July 30, 1997;
repealed, 38 SDR 105, effective December 12, 2011.
47:03:05:12. Reimbursement for other medical services. The maximum reimbursement for medical services not otherwise identified in this chapter is eighty percent of the amount charged. Only those medical facilities identified in Appendix B are subject to the provisions of this section.
Source: 23 SDR 23, effective August 22, 1996; 29 SDR 55, effective October 28, 2002.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:13. Reimbursement for dental services. To determine the maximum reimbursement for dental services, the unit value for a procedure code is multiplied by a factor of $70.26.
Source: 25 SDR 72, effective November 22, 1998; 29 SDR 55, effective October 28, 2002; 33 SDR 226, effective June 27, 2007; 39 SDR 100, effective December 6, 2012; 42 SDR 177, effective June 28, 2016; 51 SDR 54, effective November 12, 2024.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
