Definitions

(1) “Administrator” means the Chief Administrative Officer of the Bureau of Workers’ Compensation or the Administrator’s designee. (2) “Allowed Charges” or “Allowable Charges” shall mean charges as prescribed in the Bureau’s Rules, or as determined by the Administrator or the Administrator’s designee after consultation with the Bureau’s Medical Director. (3) “Bureau” means the Tennessee Bureau of Workers’ Compensation. (4) “MS-DRG” - Medicare classifications of diagnoses in which patients demonstrate similar resource consumption and length of stay patterns. (5) “Hospital” is the same as the definition for Medicare. (6) “Inpatient Services” - services rendered to a person who is formally admitted to a hospital and whose length of stay as defined by Medicare: (a) Is expected to include at least two midnights, or; (b) The medical record supports the admitting physician’s determination that the patient requires inpatient care despite the lack of a two-midnight length of stay. (7) “Institutional Services” - all non-physician services rendered within the institution by an agent of the institution. (8) “Length of Stay” (“LOS”) - number of days of admission where patient appears on midnight census. Last day of stay shall count as an admission day if it is medically necessary for the patient to remain in the hospital beyond 12:00 noon as defined by Medicare. INPATIENT HOSPITAL FEE SCHEDULE CHAPTER 0800-02-19 (9) “Medical Admission” - any hospital admission where the primary services rendered are not surgical, or in a psychiatric, or rehabilitation hospital, or in a specially designated psychiatric or rehabilitation unit within an acute care hospital. (10) “Stop-Loss Payment” (“SLP”) - an independent method of payment for an inpatient hospital stay. This provision does not apply to skilled nursing facilities. (11) “Stop-Loss Reimbursement Factor” (“SLRF”) - a factor established by the Bureau to be used as a multiplier to establish a reimbursement amount when total hospital charges have exceeded specific stop-loss thresholds. (12) “Stop-Loss Threshold” (“SLT”) - threshold of total charges established by the Bureau, beyond which reimbursement is calculated by multiplying the applicable Stop-Loss Reimbursement Factor times the total charges identifying that particular threshold. (13) “Surgical Admission” - any hospital admission where the patient has an assigned surgical MS-DRG as defined by the Medicare. (14) “Transfers between Facilities” - to move or remove a patient from one facility to another for a purpose related to obtaining or continuing medical care. This may or may not involve a change in the admittance status of the patient, i.e. patient transported from one facility to another to obtain specific care, diagnostic testing, or other medical services not available in facility in which patient has been admitted. This includes costs related to transportation of patient to obtain medical care. (15) “Trauma Admission” - means: (a) Any level 1 trauma center hospital admission in which the patient has an ICD-10 code that is (or includes) S00.00XA through S99.99XX, T07, T14 to T32, T79 and the claim includes an ICU revenue code of 020x or a CCU revenue code of 021x, or (b) Any level 1 trauma center hospital admission for any diagnosis with a trauma response revenue code of 068x and/or type of admission code, “5.” Note: this includes all hospital days that qualify as an inpatient day as defined under inpatient services. (16) “Usual and Customary Charge” means eighty percent (80%) of a specific provider’s average charges to all payers for the same procedure. (17) “Utilization Review” for workers’ compensation claims means evaluation of the necessity, appropriateness, efficiency and quality of medical care services provided to an injured or disabled employee based on medically accepted standards and an objective evaluation of the medical care services provided; provided, that “utilization review” does not include the establishment of approved payment levels or a review of medical charges or fees. (18) “Workers’ Compensation Standard Per Diem Amount” (“SPDA”) - A standardized per diem amount established for the reimbursement of hospitals for services rendered.