Page 1 of 7 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 pursuant to 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)(7) "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) (8) "Physical status modifier unit value," the number value assigned to physical status
modifiers for anesthesia services in Relative Values for Physicians;
Page 2 of 7 (11) (9) "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) (10) "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) (11) "Unit value," the number value assigned to a dental service in Relative Values for
Dentists; and
(16) (12) "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 2024, edition, published by Relative Value
Studies, Inc. Copies may be obtained from Relative Value Studies, Inc., 1675 Larimer Street, Suite
410, Denver, CO 80202 12921 S. Vista Station Blvd., Ste 200, Draper, UT
Page 3 of 7 84020; https://www.rvsdata.com/rvs-bin/order1a.cgi#oprvd. Available for order by telephone at
1-800-464-3649, option 1. Cost: $70. $700 base cost, plus an additional $25 per user.
Reference: Relative Values for Physicians, 2025, Relative Value Studies, Inc., 2020,
published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050,
Chicago, IL 60680-9920 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: $329.95$1,500
base cost, plus an additional $40 per user.
Page 4 of 7 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, 2025, Relative Value Studies, Inc., 2020,
published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050,
Chicago, IL 60680-9920 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: $329.95$1,500
base cost, plus an additional $40 per user.
Page 5 of 7 47:03:05:05. Reimbursement criteria. To be reimbursed be eligible for reimbursement, the a
charge must be for reasonable and necessary medical 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 that exceed 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
Page 6 of 7 99075 $ 14.37 1st hour, $1.78 each additional 15 min minute
99076-99199 $ 6.57
99201-99450 $ 8.00 12.00
99455-99456 $ 19.33 1st hour, $2.41 each additional 15 min minute
99460-99499 $ 8.00 12.00
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 considered Relativity Not Established (RNE)
or By Report (BR) in Relative Values for Physicians, the reimbursement is 80% eighty percent of
the provider's charge.
For purposes of this section, "health care provider" means a person or entity providing
medical services, dental services, or treatment to an employee for a compensable injury or
disability.
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, 2025, Relative Value Studies, Inc., 2020,
published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050,
Chicago, IL 60680-9920 Relative Value Studies, Inc., 12921 S Vista Station Blvd, Ste 200 Draper,
Page 7 of 7 UT 84020. Available for order by telephone at 1-800-464-3649, option 1. Cost: $329.95$1,500
base cost, plus an additional $40 per user.