General Rules

(1) These Inpatient Hospital Fee Schedule Rules are applicable to all inpatient services as defined herein. These include medical, surgical, rehabilitation, and/or psychiatric services rendered in a hospital to injured or ill workers claiming medical benefits pursuant to the Tennessee Workers’ Compensation Law. Maximum fees for outpatient hospital services are not addressed in these Inpatient Hospital Fee Schedule Rules, but are addressed in Rule 0800-02-18-.07 of the Medical Fee Schedule Rules, Chapter 0800-02-18-.01 et seq. These Inpatient Hospital Fee Schedule Rules are established pursuant to Tenn. Code Ann. § 50-6- 204. They shall be used in conjunction with the Rules for Medical Payments, Chapter 0800- 02-17-.01 et seq., and the Medical Fee Schedule Rules, Chapter 0800-02-18-.01 et seq., as the definitions and provisions set forth in those rules are incorporated as if set forth fully herein. Providers rendering medically appropriate care outside of the state of Tennessee to an injured employee pursuant to the Tennessee Workers’ Compensation Law may be paid in accordance with the medical fee schedule, law, and rules governing in the jurisdiction where such medically appropriate care is provided, if a waiver is granted by the Bureau. (2) General Information (a) Reimbursements shall be determined for services rendered in accordance with these Fee Schedule Rules and shall be considered to be inclusive unless otherwise expressly noted in these Rules. (b) The most recent Medicare procedures and guidelines are hereby adopted and incorporated as part of these Rules as if fully set out herein and shall be effective upon adoption and implementation by the CMS. All such Medicare procedures and guidelines are applicable unless these Rules set forth a different procedure or guideline. Whenever there is no specific maximum fee or methodology for reimbursement set forth in these Rules for a service, diagnostic procedure, equipment, etc., then the maximum amount of reimbursement shall be 100% of the Medicare allowable amount and the Medicare guidelines and procedures effective on the date of service shall be followed in arriving at the correct amount. Whenever there is no applicable Medicare code, the service, equipment, diagnostic procedure, etc. shall be reimbursed up to a maximum of the usual and customary amount, as defined in Rule 0800-02-17-.03. All Medicare rules shall be applied that are effective on the date of service or the date of discharge in accordance with Medicare guidelines. (c) Reimbursement for a compensable workers’ compensation claim shall be the lesser of the hospital’s usual and customary charges or the maximum amount allowed under this Inpatient Hospital Fee Schedule. (d) Inpatient hospitals shall be grouped into the following separate peer groupings: INPATIENT HOSPITAL FEE SCHEDULE CHAPTER 0800-02-19 1. Peer Group 1 Hospitals; 2. Peer Group 2 Rehabilitation Hospitals; 3. Peer Group 3 Psychiatric Hospitals; 4. Peer Group 4 Designated Level 1 Trauma Centers. (e) For each inpatient claim submitted, the provider shall assign a Medicare Diagnosis Related Group (“MS-DRG”) code which appropriately reflects the patient’s primary cause of hospitalization. (f) Prospective utilization review is required for non-emergent, non-urgent inpatient services. Emergency or urgent admissions require utilization review to begin within one (1) business day of the employer receiving notification of the admission.