General Information And Instructions For Use

(1) Format (a) These Rules address and consist of the following sections: General Guidelines, General Medicine (including Evaluation and Management), General Surgery, Neuro- and Orthopedic Surgery, Radiology, Pathology, Anesthesiology, Injections, Durable Medical Equipment, Implants and Orthotics, Pharmacy, Physical and Occupational Therapy, Ambulatory Surgical Centers and Outpatient Hospital Care, Chiropractic, Ambulance Services and Clinical Psychological Services. Providers should consult and use the section(s) containing the procedure(s) they perform, or the service(s) they render, together with the appropriate sections of the Rules for Medical Payments, and the Inpatient Hospital Fee Schedule Rules, if applicable, and the National Council for Prescription Drug Programs, Property & Casualty/Workers’ Compensation, Universal Claim Form (“NCPDP WC/PC UCF”) for pharmacies. (2) Reimbursement (a) Unless otherwise indicated herein, the most recent, effective Medicare procedures and guidelines are hereby adopted and incorporated as part of these Rules as if fully set out herein and effective upon adoption and implementation by the CMS. Whenever there is no specific fee or methodology for reimbursement set forth in these Rules or rate tables for a service, diagnostic procedure, equipment, etc., then the maximum amount of reimbursement shall be 100% of the Medicare allowable amount, in effect on the date of service. The Medicare guidelines and procedures, in effect at the date of service, shall be followed in arriving at the correct amount. For purposes of these Rules, the base Medicare amount may be adjusted at the discretion of the Administrator based upon the Medicare Economic Index (“MEI”) adjustment. Whenever there is no applicable Medicare code or method of reimbursement, the service, equipment, diagnostic procedure, etc. shall be reimbursed at the usual and customary amount as defined in the Rules for Medical Payments. (b) These comparisons shall be determined based on the entire bill or an amount due for a service, rather than on a line-by-line basis. Reimbursement to all providers shall be the lesser of the following: 1. The total of the provider’s usual charge; or 2. The total of the fee or fees listed in the rate tables, after applying any applicable modifiers, methodologies, or exceptions set forth in these Rules; or 100% of the Medicare rate if the code is not listed in the rate tables, or the methodology is not set forth in these Rules; or MEDICAL FEE SCHEDULE CHAPTER 0800-02-18 3. The MCO/PPO or any other contracted price. (3) Fee Schedule Calculations (a) The Medical Fee Schedule maximum reimbursement amount for professional services is listed in the accompanying rate tables by CPT® category (i.e., evaluation and management, anesthesia, surgery). If the fee for a current service or procedure is not listed in the rate tables or included in the Rules, the maximum allowable reimbursement amount is 100% of the Tennessee-specific Medicare allowable amount calculated in accordance with Medicare guidelines and methodology effective on the date of service, except where a waiver has been granted by the Bureau. (b) Dental Reimbursement shall be set at the 60th percentile of FAIR Health’s FH® Charge Benchmarks at the Tennessee state level and shall be included in the rate tables published by Fair Health and reviewed on an annual basis by the Administrator in consultation with the Medical Payment Committee and Advisory Council on Workers’ Compensation pursuant to T.C.A. § 50-6-204. (c) Medical Reimbursement shall be based on the following percentages of CMS for Tennessee. Codes that are not valued by CMS are gap-filled using FAIR Health data provided to the Bureau each year and reviewed on an annual basis by the Administrator in consultation with the Medical Payment Committee and Advisory Council on Workers’ Compensation pursuant to T.C.A. § 50-6-204. Board certified physicians in certain specialties may be eligible for additional reimbursement. See 0800-02-18-.02(4), State Specific Modifiers. 275% Surgery - Board Certified Orthopaedic and Neurosurgeons (with “ON” modifier, see 0800-02-18-.02(4)) 200% Surgery - all other providers 200% Radiology 200% Pathology 180% Laboratory 180% Physical, occupational, and speech therapy 180% Chiropractic 200% Evaluation and Management* 200% General Medicine* 200% Emergency Care (CPT® 99281-99292) 150% Home Health Services *See 0800-02-18-.02(4) for adjustments for certain board-certified physicians. (4) State-Specific Modifiers (a) The appropriate modifiers shall be used for billing as listed below: (b) Modifier “ON” - Board certified or board eligible Orthopedists and Neurosurgeons may use the modifier “ON” on the appropriate billing form for reimbursement up to 137.5% of the fees listed in the rate tables (275% of CMS) on surgical codes only. (CPT® 10004-69999) (c) Modifier “NP” - the following Non-Physician Practitioners properly licensed or certified to perform services shall be reimbursed at 85% of the fees listed in the rate tables. 1. Licensed psychologists and other practitioners providing psychological services. See 0800-02-18-.14, Clinical Psychological Service Guidelines. MEDICAL FEE SCHEDULE CHAPTER 0800-02-18 2. Physician Assistant (PA) or Advanced Practice Nurse (APN) (i) “Incident to” rules do not apply. (ii) 85% reimbursement applies to all services except when providing assistance at surgery. (iii) See 0800-02-18-.04(2)(b) for surgical assistant billing. 3. The payor may verify a provider’s eligibility by consulting the Tennessee Department of Health’s database or by requesting documentation from the provider. (5) Modifiers 22 and 25 - When Modifier 22 or 25 is used, a report explaining the medical necessity of the situation shall be submitted to the employer. It is not appropriate to use Modifier 22 or 25 for routine billing. The maximum allowable additional amount under these Rules for Modifier 22 is 50%, not to exceed billed charges of the primary procedure. (6) Modifier “CP”: Certified Physician Program in Workers’ Compensation (CPP) - Physicians certified through the Certified Physician Program shall receive an additional reimbursement for the following services (these fees may be subject to contract negotiations, shall not be billed in the applicable Medicare “global period” and shall only be used for Tennessee jurisdictional claims): (a) Initial Assessment (billed as an additional code Z0815) ………………..................... $80; (b) Subsequent visit (billed as an additional code Z0816)……....................................... .$40; (c) Assessment of Permanent Impairment and timely completion of the Final Medical Report (C30-A) (billed as an additional code Z0817)............................................. .$100. (7) Forms - The following forms (or their official replacements) should be used for provider billing: the effective current version of the CMS-1500 and UB-04 (CMS-1450) or the electronic equivalents. (8) Bills for reimbursement shall be sent directly to the employer responsible for reimbursement. In most instances, this is the Insurance Carrier or the Self-Insured Employer. Insurance Carriers and/or Employers shall furnish this billing information to the Providers, and such information shall be accurate and updated, within thirty (30) calendar days of any change to the billing address of the responsible party, either by mail, e-mail or electronic submission.