South Dakota Administrative Rules
Title 47 - Department of Labor And Regulation
Article 47:03 - Workers' compensation
Chapter 47:03:05 - Medical fee schedules
Section 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.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
Properly submitted medical bill, § 47:03:09:01.
Relative Values for Physicians, Relative Value Studies, Inc., 2020. published by Optum 360, LLC. Copies may be obtained from Optum 360, LLC, PO Box 88050, Chicago, IL 60680-9920. Cost $329.95.
