Tenn. Comp. R. & Regs. 0800-02-17-.03 - DEFINITIONS
The following definitions are for the purposes of and are applicable to the Rules for Medical Payments (Chapter 0800-02-17), the Medical Fee Schedule Rules (Chapter 0800-02-18) and the Inpatient Hospital Fee Schedule Rules (Chapter 0800-02-19):
(1) "Law" means
Tennessee's Workers' Compensation Law, Tenn. Code Ann. §§
50-6-101 et seq. as currently
enacted by the Tennessee General Assembly, specifically including any future
enactments by the Tennessee General Assembly involving amendments, deletions,
additions, repeals, or any other modification, in any form of the Workers'
Compensation Law.
(2) "Adjust"
means that an employer changes a health care provider's request for payment,
including but not limited to:
(a) Applies the
maximum fee allowable under these Rules;
(b) Applies an agreed upon discount to the
provider's usual bill, in accordance with the requirement in T.C.A. §
50-6-215;
(c) Adjusts to a usual and customary amount
when the maximum fee is By Report (BR);
(d) Reduces or denies all or part of a
properly submitted bill for payment as a result of bill review;
(e) Recodes a procedure.
(3) "Administrator" means the Chief
Administrative Officer of the Bureau of Workers' Compensation or the
Administrator's designee.
(4)
"Appropriate care" means health care that is suitable for a particular person,
condition, occasion, or place as determined by the Administrator or the
Administrator's designee after consultation with the Medical
Director.
(5) "Bill" means a
request by a provider submitted to an employer for payment for health care
services provided in connection with a compensable injury, illness or
occupational disease.
(6) "BR" (By
Report) means that the procedure is not assigned a maximum fee and requires a
written description. The description shall be included on the bill or attached
to the bill and shall include the following information, as appropriate:
(a) Copies of operative reports;
(b) Consultation reports;
(c) Progress notes;
(d) Office notes or other applicable
documentation;
(e) Description of
equipment or supply (when that is the bill).
(7) "Bureau" means the Tennessee Bureau of
Workers' Compensation as defined in T.C.A. §
50-6-102, an autonomous unit
attached to the Tennessee Department of Labor and Workforce Development for
administrative matters only pursuant to T.C.A. §
4-3-1409.
(8) "Case" means a compensable injury,
illness or occupational disease identified by the worker's name and date of
injury, illness or occupational disease.
(9) "CMS" means the Centers for Medicare
& Medicaid Services. The rules promulgated by CMS used in these chapters
are referred to as "Medicare."
(10)
"Complete procedure" means a procedure containing a series of steps which are
not to be billed separately, as defined by Medicare.
(11) "Consultant service" means; in regard to
the care of a patient with a covered injury and illness; an examination,
evaluation, and opinion rendered by a health care specialist when requested by
the authorized treating practitioner or by the employee; and which includes a
history, examination, evaluation of treatment, and a written report. If the
consulting practitioner assumes responsibility for the continuing care of the
patient, subsequent service(s) cease(s) to be a consultant service.
(12) "CPT®" means the edition of the
American Medical Association's Current Procedural Terminology
in effect on the date of service.
(13) "Critical care" has the same meaning as
defined by Medicare.
(14) "Day"
means a calendar day, unless otherwise designated in these Rules.
(15) "Diagnostic procedure" means a service
which aids in determining the nature and/or cause of an occupational disease,
illness or injury.
(16) "Diagnostic
Code" means the properly constructed numeric code from the International
Classification of Diseases, version ICD-9-CM for dates of service before
October 1, 2015. For dates of service on or after October 1, 2015, it means the
properly constructed ICD-10-CM alpha-numeric code.
(17) "Dispute" means a disagreement between
an employer and a health care provider on interpretation, payment under, or
application of these Rules.
(18)
"MS-DRG" (Diagnosis Related Group) means one of the classifications of
diagnoses in which patients demonstrate similar resource consumption and length
of stay patterns as defined for Medicare.
(19) "Durable Medical Equipment" or "DME" is
equipment which:
(a) Can withstand repeated
use;
(b) Is primarily and
customarily used to serve a medical purpose;
(c) Generally, is not useful to a person in
the absence of illness, injury or occupational disease; and
(d) Is appropriate for use in the
home.
(20) "Employer"
shall have the same meaning as defined in T.C.A. §
50-6-102, but also includes an
employer's insurer, third party administrator, self-insured employers,
self-insured pools, and trusts, as well as the employer's legally authorized
representative or legal counsel, and agents to accomplish billing and payment
transactions, as applicable.
(21)
"Established patient" has the same meaning as in the version of the CPT®
book and Medicare guidelines in effect on the date of service.
(22) "Expendable medical supply" means a
disposable article which is needed in quantity on a daily or monthly
basis.
(23) "Focused review" means
the evaluation of a specific health care service or provider to establish
patterns of use and dollar expenditures.
(24) "Follow-up care" means the care which is
related to the recovery from a specific procedure, and which is considered part
of the procedure's maximum allowable payment, as listed in the rate tables
under the Follow Up Days (FUD) column but does not include care for
complications.
(25) "Follow-up days
(FUD)" means the days of care following a surgical procedure that are included
in the procedure's maximum allowable payment, as listed in the rate tables but
does not include care for complications.
(26) "Follow-up visits" means office visits
following a surgical procedure which are included in the procedure's maximum
allowable payment, as listed in the rate tables but does not include care for
complications.
(27) "Gap filled
codes" are procedural codes not valued by Medicare but for which maximum
reimbursement amounts are included in the fee schedule rate tables.
(28) "Health care organization" means a group
of practitioners or individuals joined together to provide health care services
and includes, but is not limited to, a freestanding surgical outpatient
facility, health maintenance organization, an industrial or other clinic, an
occupational health care center, a home health agency, a visiting nurse
association, a laboratory, a medical supply company, or a community mental
health center.
(29) "Health care
review" means the review of a health care case or bill, or both, by an
employer.
(30) "Health Care
Specialist" means a board-certified practitioner, board-eligible practitioner,
or a practitioner otherwise considered an expert in a field of health care
service by virtue of education, training, and experience generally accepted by
practitioners in that particular field of health care service.
(31) "Implantables" or "Surgical Implants"
are items that are surgically inserted into the human body for the purpose of
replacing, repairing or improving function or promoting healing that are
designed and intended to remain in the human body for a minimum of 30 days or
in accordance with Medicare.
(32)
"Inappropriate health care" means health care that is not suitable for a
particular person, condition, occasion, or place as determined by the
Administrator or the Administrator's designee after consultation with the
Bureau's Medical Director.
(33)
"Incidental surgery" means a surgery performed through the same incision, on
the same day, by the same doctor, and not related to the original or covered
diagnosis that is in accord with the Medicare rules.
(34) "Independent Medical Examination" means
an examination and evaluation conducted by a practitioner who has not
previously been involved in providing care to the examinee. There is no
doctor/therapist-patient relationship. This does not include one conducted
under the Bureau's Medical Impairment Rating Registry ("MIRR")
Program.
(35) "Independent
procedure" means a procedure which may be carried out by itself, separate and
apart from the total service that usually accompanies it according to CPT®
guidelines.
(36) "Injury" has the
same meaning as defined in T.C.A. §
50-6-102.
(37) "Inpatient services" mean services
rendered to a person who is formally admitted to a hospital and whose condition
is such that requires inpatient admission in accordance with industry standard
guidelines.
(38) "Institutional
services" mean all non-physician services rendered within the institution by an
agent of the institution.
(39)
"Maximum allowable payment or maximum allowable reimbursement (MAR)" means the
maximum fee for a procedure as listed in the rate tables or otherwise
established by these Rules or the provider's usual and customary bill as
defined in these Rules, whichever is less, except as otherwise might be
specified. In no event shall reimbursement be in excess of the Bureau's Medical
Fee Schedule, unless otherwise authorized by the administrator.
(40) "Maximum fee" means the maximum
allowable payment for a procedure established by this rule, the Medical Fee
Schedule and the Inpatient Hospital Fee Schedule.
(41) "Medical admission" means any hospital
admission where the primary services rendered are not surgical or in an acute
care hospital where the admission is to special unit such as inpatient
psychiatric or rehab beds, or in a separately licensed psychiatric or
rehabilitation hospital.
(42)
"Medical Director" means the Bureau's Medical Director appointed by the
Administrator pursuant to T.C.A. §
50-6-126.
(43) "Medical only case" means a case which
does not involve lost work time.
(44) "Medical supply" means either a piece of
durable medical equipment or an expendable medical supply.
(45) "Medicare Conversion Factor" is the
amount in dollars that Medicare multiplies by the relative values units (RVUs)
assigned to the procedure code to determine the fee. The RVUs are first
multiplied by the Geographic Practice Cost Indices ("GPCI") for Tennessee.
Conversion factors are modified on a regular basis. When referenced in the fee
schedule, or rate tables, the Medicare conversion factor used in the applicable
rate table for the date of service shall be used.
(46) "Modifier code" means a 2-digit number
or alphabetical designation used in conjunction with the procedure code to
describe circumstances which arise in the treatment of an injured or ill
employee.
(47) "New patient"
designation for billing purposes means a patient who is new to the provider
according to the definitions used by Medicare on the date of service.
(48) "Operative report" means the
practitioner's written description of the surgery and includes all of the
following:
(a) A preoperative
diagnosis;
(b) A postoperative
diagnosis;
(c) A step-by-step
description of the surgery;
(d) An
identification of problems which occurred during surgery;
(e) The condition of the patient, when
leaving the operating room, the practitioner's office, or the health care
organization.
(49)
"Ophthalmologist" shall be defined according to T.C.A. §
71-4-102(3).
(50) "Optician" shall mean a licensed
dispensing optician as set forth in T.C.A. §
63-14-103.
(51) "Optometrist" means an individual
licensed to practice optometry.
(52) "Optometry" shall be defined according
to T.C.A. §
63-8-102(12).
(53) "Orthotic equipment" means an orthopedic
apparatus designed to support, align, prevent, correct deformities, or improve
the function of a movable body part.
(54) "Orthotist" means a person skilled in
the construction and application of orthotic equipment.
(55) "Outpatient service" means a service
provided by the following, but not limited to, types of facilities: physicians'
offices and clinics, hospital emergency rooms, hospital outpatient facilities,
community mental health centers, outpatient psychiatric hospitals, outpatient
psychiatric units, and freestanding surgical outpatient facilities also known
as ambulatory surgical centers.
(56) "Package" means a surgical procedure
that includes but is not limited to all of the following components:
(a) The operation itself;
(b) Local infiltration;
(c) Topical anesthesia when used;
(d) The normal or global follow-up period
and/or visits.
(57)
"Pattern of practice" means repeated, similar violations over a three-year
period of the Tennessee Medical Fee Schedule Rules.
(58) "Pharmacy" means the place where the
science, art, and practice of preparing, preserving, compounding, dispensing,
and giving appropriate instruction in the use of drugs is practiced and
governed by the Board of Pharmacy.
(59) "Practitioner" means a person licensed,
registered, or certified as an audiologist, chiropractic physician, doctor of
dental surgery, doctor of medicine, doctor of osteopathy, doctor of podiatry,
doctor of optometry, nurse, nurse anesthetist, nurse practitioner, occupational
therapist, orthotist, pharmacist, physical therapist, physician assistant,
prosthetist, psychologist, physical therapy assistant, occupational therapy
assistant or other person licensed, registered, or certified as a health care
professional, or their agents used to accomplish medical records, billing and
payment transactions.
(60)
"Preauthorization" for workers' compensation claims means that the employer
prospectively or concurrently authorizes the payment of medical benefits.
Preauthorization for workers' compensation claims does not mean that the
employer accepts the claim or has made a final determination on the
compensability of the claim. Preauthorization for workers' compensation claims
does not include utilization review.
(61) "Primary procedure" means the
therapeutic procedure most closely related to the principal
diagnosis.
(62) "Procedure" means a
unit of health service.
(63)
"Procedure code" means an alpha/numeric or numeric sequence used to identify a
service performed and billed by a qualified provider.
(64) "Properly submitted and complete bill"
means a request for a provider for payment of health care services submitted to
the employer on the appropriate forms which are completed pursuant to this rule
or the rules appropriate to electronic billing. To be properly submitted and
complete, the bill shall:
(a) Identify:
1. The injured employee who received the
service;
2. The employer and the
responsible paying agent with information sufficient to contact the responsible
party in case of a dispute or questions. This information shall be provided by
the payer if the bill is adjusted, contested, or rejected and shall include a
clear explanation of the reasons;
3. The health care provider with an IRS, NPI
or other appropriate identifier;
4.
The medical service product;
5.
Other information required by the form;
(b) Include a valid MS-DRG, revenue code,
CPT® code, or HCPCS code as applicable;
(c) Include an ICD-10-CM code where
necessary;
(d) Have attached, in
legible text, all supporting documentation required for the particular bill
format, including, but not limited to, medical reports and records, evaluation
reports, narrative reports, assessment reports, progress reports/notes,
clinical notes, hospital records and diagnostic test results that may be
expressly required by law or can reasonably be expected by the payer or its
agent under the laws of Tennessee.
(65) "Prosthesis" means an artificial
substitute for a missing body part.
(66) "Prosthetist" means a person skilled in
the construction and application of prosthesis.
(67) "Provider" means a facility, health care
organization, or a practitioner, or their agents to accomplish medical records,
correspondences, billing and payment transactions.
(68) "Rate Table or Rate Tables" means the
established fees for services provided by the Bureau and updated in accordance
with these Rules.
(69) "Reject"
means that an employer denies partial or total payment to a provider or denies
a provider's request for reconsideration. Notification of any full or partial
rejection shall be made within fifteen (15) business days of receipt of the
bill by the employer.
(70) "RVU"
means relative value unit that is assigned under the Medicare Resource Based
Relative Value System (RBRVS) used in the rate tables in effect on the date of
service.
(71) "Secondary procedure"
means a surgical procedure which is performed to ameliorate conditions that are
found to exist during the performance of a primary surgery, and which is
considered an independent procedure that may not be performed as a part of the
primary surgery or for the existing condition, as defined by
Medicare.
(72) "Stop-Loss Payment"
or "SLP" means an independent method of payment for an inpatient hospital
stay.
(73) "Stop-Loss Reimbursement
Factor" or "SLRF" means a factor established by the Administrator to be used as
a multiplier to establish a reimbursement amount when total hospital bills have
exceeded specific stop-loss dollar thresholds.
(74) "Stop-Loss Threshold" or "SLT" means a
dollar threshold of bills established by the Administrator, beyond which
reimbursement is calculated by multiplying the applicable SLRF times the total
dollars billed following that particular dollar threshold.
(75) "Surgical admission" means any hospital
admission for which the patient has a surgical MS-DRG as defined by
CMS.
(76) "Tennessee Specific
Conversion Percentage" is a multiplier applied to an applicable service for an
eligible medical specialty category. The appropriate medical specialty
categories are listed in Chapter 0800-02-18.
(77) "Timely filing of bills for medical
services" means the period of time within which a request for payment from a
provider shall be billed consistent with Medicare guideline time
limits.
(78) "Timely payment" means
the period of time that the employer has to remit payment to the
provider.
(79) "Transfer between
facilities" means to move or remove a patient from one facility to another for
a purpose related to obtaining or continuing medical care. The transfer 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 the facility in which the
patient has been admitted. The transfer between facilities shall include costs
related to transportation of patient to obtain medical care.
(80) "Usual and customary" (U&C) means
eighty percent (80%) of a specific provider's billed charges.
(81) "CMS-1500, CMS-1450, UB-04", their
electronic equivalents or their successors means the most recent industry
standard health insurance claim forms maintained for use by medical care
providers and institutions, including the ADA form for dentists and the NCPDP
WC/PC UCF for pharmacies.
(82)
"Utilization Review" means evaluation of the necessity, appropriateness,
efficiency and quality of medical services, including the prescribing of one
(1) or more Schedule II, III or IV controlled substances for pain management
for a period of time exceeding ninety (90) days from the initial prescription
of such controlled substances, provided to an injured or disabled employee
based upon 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, a review of medical
charges or fees, or an initial evaluation of an injured or disabled employee by
a physician specializing in pain management. "Utilization review," also known
as "Utilization management," does not include the evaluation or determination
of causation or the compensability of a claim. For workers' compensation
claims, "utilization review" is not a component of preauthorization. The
employer shall be responsible for all costs associated with utilization review
and shall in no event obligate the employee, health care provider or Bureau to
pay for such services.
Notes
Authority: T.C.A. §§ 50-6-102, 50-6-202, 50-6-204, 50-6-205, 50-6-226, and 50-6-233 (Repl. 2005) and Public Chapters 282 & 289 (2013).
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