(1) Format
(a) These Rules address and consist of thefollowing sections: General Guidelines, General Medicine (including Evaluationand Management), General Surgery, Neuro-and Orthopedic Surgery, Radiology,Pathology, Anesthesiology, Injections, Durable Medical Equipment, Implants andOrthotics, Pharmacy, Physical and Occupational Therapy, Ambulatory SurgicalCenters and Outpatient Hospital Care, Chiropractic, Ambulance Services andClinical Psychological Services. Providers should consult and use thesection(s) containing the procedure(s) they perform, or the service(s) theyrender, together with the appropriate sections of the Rules for MedicalPayments, and the Inpatient Hospital Fee Schedule Rules, if applicable, and theNational Council for Prescription Drug Programs, Property &Casualty/Workers' Compensation, Universal Claim Form ("NCPDP WC/PC UCF") forpharmacies.
(2)Reimbursem*nt
(a) Unless otherwise indicatedherein, the most recent, effective Medicare procedures and guidelines arehereby adopted and incorporated as part of these Rules as if fully set outherein and effective upon adoption and implementation by the CMS. Wheneverthere is no specific fee or methodology for reimbursem*nt set forth in theseRules or rate tables for a service, diagnostic procedure, equipment, etc., thenthe maximum amount of reimbursem*nt shall be 100% of the Medicare allowableamount, in effect on the date of service. The Medicare guidelines andprocedures, in effect at the date of service, shall be followed in arriving atthe correct amount. For purposes of these Rules, the base Medicare amount maybe adjusted at the discretion of the Administrator based upon the MedicareEconomic Index ("MEI") adjustment. Whenever there is no applicable Medicarecode or method of reimbursem*nt, the service, equipment, diagnostic procedure,etc. shall be reimbursed at the usual and customary amount as defined in theRules for Medical Payments.
(b)These comparisons shall be determined based on the entire bill or an amount duefor a service, rather than on a line-by-line basis. Reimbursem*nt to allproviders shall be the lesser of the following:
1. The provider's usual charge; or
2. The fee listed in the rate tables, afterapplying any applicable modifiers, methodologies, or exceptions set forth inthese Rules; or 100% of the Medicare rate if the code is not listed in the ratetables, or the methodology is not set forth in these Rules; or
3. The MCO/PPO or any other contractedprice.
(3)Fee Schedule Calculations
(a) The Medical FeeSchedule maximum reimbursem*nt amount for professional services is listed inthe accompanying rate tables by CPT® category (i.e., evaluation andmanagement, anesthesia, surgery). If the fee for a current service or procedureis not listed in the rate tables or included in the Rules, the maximumallowable reimbursem*nt amount is 100% of the Tennessee-specific Medicareallowable amount calculated in accordance with Medicare guidelines andmethodology effective on the date of service, except where a waiver has beengranted by the Bureau.
(b) DentalReimbursem*nt shall be set at the 60th percentile of FAIR Health's FH®Charge Benchmarks at the Tennessee state level and shall be included in therate tables published by Fair Health and reviewed on an annual basis by theAdministrator in consultation with the Medical Payment Committee and AdvisoryCouncil on Workers' Compensation pursuant to T.C.A. §50-6-204.
(c) Medical Reimbursem*nt shall be based onthe following percentages of CMS for Tennessee. Codes that are not valued byCMS are gap-filled using FAIR Health data provided to the Bureau each year andreviewed on an annual basis by the Administrator in consultation with theMedical Payment Committee and Advisory Council on Workers' Compensationpursuant to T.C.A. §50-6-204. Board certified physicians in certainspecialties may be eligible for additional reimbursem*nt. See 0800-02-18-.02(4), State Specific Modifiers.
275% | Surgery - Board Certified Orthopaedic andNeurosurgeons (with "ON" modifier, see 0800-02-18-.02(4)) |
200% | Surgery - all other providers |
200% | Radiology |
200% | Pathology |
180% | Laboratory |
130% | Physical, occupational, and speech therapy |
130% | Chiropractic |
160% | Evaluation and Management* |
160% | General Medicine* |
200% | Emergency Care (CPT® 99281-99292) |
100% | Home Health Services |
*See 0800-02-18-.02(4) for adjustments for certain board-certified physicians.
(4) State-Specific Modifiers
(a) Modifier "ON" - Board certified or boardeligible Orthopedists and Neurosurgeons may use the modifier "ON" on theappropriate billing form for reimbursem*nt up to 137.5% of the fees listed inthe rate tables (275% of CMS) on surgical codes only. (CPT®10004-69999)
(b) Modifier "OP" -Physicians board certified or board eligible in the following specialties andby the following organizations may use the modifier "OP" on the appropriatebilling form for reimbursem*nt up to 112.5% of the fees listed in the ratetables (180% of CMS) on Evaluation & Management and General Medicine codesonly:
1. Physicians board certified inOccupational Medicine by the American Board of Preventive Medicine, Specialtyof Occupational Medicine (ABPM);
2.Physicians board certified in Physical Medicine and Rehabilitation by theAmerican Board of Physical Medicine and Rehabilitation (ABPMR);
3. Pulmonologists board certified inpulmonary disease by the American Board of Internal Medicine (ABIM);
4. Psychiatrists board certified by theAmerican Board of Psychiatry and Neurology (ABPN);
5. Neurologists board certified by theAmerican Board of Psychiatry and Neurology (ABPN); and
6. Cardiologists board certified incardiovascular disease by the American Board of Internal Medicine(ABIM).
(c) Modifier"NP" - the following Non-Physician Practitioners properly licensed or certifiedto perform services shall be reimbursed at 85% of the fees listed in the ratetables.
1. Licensed psychologists and otherpractitioners providing psychological services. See 0800-02-18-.14, ClinicalPsychological Service Guidelines.
2. Physician Assistant (PA) or AdvancedPractice Nurse (APN)
(i) "Incident to" rulesdo not apply.
(ii) 85%reimbursem*nt applies to all services except when providing assistance atsurgery.
(iii) See 0800-02-18-.04(2)(b) for surgical assistant billing.
3. The payor may verify a provider'seligibility by consulting the Tennessee Department of Health's database or byrequesting documentation from the provider.
(5) Modifiers 22 and 25 - When Modifier 22 or25 is used, a report explaining the medical necessity of the situation shall besubmitted to the employer. It is not appropriate to use Modifier 22 or 25 forroutine billing. The maximum allowable additional amount under these Rules forModifier 22 is 50%, not to exceed billed charges of the primaryprocedure.
(6) Certified PhysicianProgram in Workers' Compensation (CPP) - Physicians certified through theCertified Physician Program shall receive an additional reimbursem*nt for thefollowing services:
(a) Initial Assessment(billed as an additional code Z0815) .................. $80;
(b) Subsequent visit (billed as an additionalcode Z0816) ................... $40;
(c) Assessment of Permanent Impairment andtimely completion of the Final Medical Report (C30-A) (billed as an additionalcode Z0817) .................... $100.
(7) Forms - The following forms (or theirofficial replacements) should be used for provider billing: the effectivecurrent version of the CMS-1500 and UB-04 (CMS-1450) or the electronicequivalents.
(8) Bills forreimbursem*nt shall be sent directly to the employer responsible forreimbursem*nt. In most instances, this is the Insurance Carrier or theSelf-Insured Employer. Insurance Carriers and/or Employers shall furnish thisbilling information to the Providers, and such information shall be accurateand updated, within thirty (30) calendar days of any change to the billingaddress of the responsible party, either by mail, e-mail or electronicsubmission.
