South Dakota Workers' Compensation Physical Therapy Fee Schedule Explained

Overview of South Dakota Workers' Compensation PT Fees

South Dakota's workers' compensation program sets specific reimbursement rates for physical therapy (PT) services based on the state's fee schedule, which differs from private insurance fee structures. Rates are tied to the South Dakota Medicaid fee schedule and are updated biennially by the Department of Labor and Regulation. Providers must bill using the designated CPT codes and apply the state‑mandated multiplier to receive full payment.

Key Fee Components

The schedule separates fees into three primary categories: evaluation, therapeutic procedures, and modalities. Each category has a base rate; the final reimbursable amount is the base rate multiplied by a 1.0 factor for in‑network providers. Out‑of‑network clinicians may receive a reduced percentage, typically 80%, unless a contract specifies otherwise.

Evaluation Services

Initial and re‑evaluation visits are billed with CPT codes 97161‑97164. The base rates range from $45 for a brief screening to $85 for a comprehensive functional evaluation.

Therapeutic Procedures

Standard PT interventions—manual therapy, therapeutic exercises, and gait training—use codes 97110‑97112. Base rates hover between $30 and $55 per 15‑minute unit, with a minimum of one unit per session.

Modalities

Modal treatments such as ultrasound (97035), electrical stimulation (97014), and hot/cold packs (97010) have set rates from $20 to $40 per application, depending on equipment and time used.

Billing Rules and Documentation

Claims must include the worker's injury date, a clear medical necessity statement, and the exact CPT code. Supporting notes should detail the evaluation findings, treatment goals, and progress. Failure to document duration or specific modality parameters can trigger a denial or reduced payment.

Common Pitfalls

• Using private‑insurance fee amounts instead of the state schedule.
• Submitting units that exceed the documented treatment time.
• Omitting the required "workers' compensation" modifier on the claim form.

Fee Schedule Summary Table