Tenn. Comp. R. & Regs. 0800-02-18-.01 - MEDICARE-BASIS FOR SYSTEM, APPLICABILITY, EFFECTIVE DATE AND CODING REFERENCES

(1) The Medical Fee Schedule of the Tennessee Bureau of Workers' Compensation (Bureau) is a Medicare-based system with Tennessee Specific Conversion Percentages. These Medical Fee Schedule Rules apply to all injured employees claiming benefits under the Tennessee Workers' Compensation Law. The Medical Fee Schedule is based upon the Centers for Medicare and Medicaid Services ("CMS") Resource Based Relative Value Scale ("RBRVS") system, utilizing the CMS' relative value units ("RVUs") adjusted for the Tennessee Geographic Practice Index ("GPCI"). CMS base units are used for anesthesia services. Tennessee Specific Conversion Percentages adopted by the Tennessee Bureau of Workers' Compensation are applied in these Rules. Services that are not valued by Medicare are gap filled, when possible, based on 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. These Medical Fee Schedule Rules shall be used in conjunction with the current American Medical Association's (AMA) Current Procedural Terminology (CPT®), CMS' Healthcare Common Procedure Coding System ("HCPCS"), the National Correct Coding Initiative edits ("NCCI") and current effective Medicare procedures and guidelines, unless specifically exempted in these rules. 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, upon waiver granted by the Bureau.

(2) These Medical Fee Schedule Rules shall also be used in conjunction with Rules for Medical Payments, Chapter 0800-02-17, and the Inpatient Hospital Fee Schedule Rules, Chapter 0800-02-19. The definitions set out in those rules, as well as the other general provisions, including but not limited to those regarding electronic billing and prompt payment of provider's bills, are adopted by reference as if set forth fully herein.

(3) These Medical Fee Schedule Rules become effective following promulgation and upon adoption by the Bureau and remain in effect until modified or replaced by the Bureau. These Rules apply to all services provided on or after the effective date.

(4) The reimbursement rates shall be set forth in rate tables as an appendix to the Medical Fee Schedule. They shall be effective following promulgation and upon adoption by the Bureau of the Medical Fee Schedule Rules and annually on April 1 thereafter.

Notes

Tenn. Comp. R. & Regs. 0800-02-18-.01

Public necessity rule filed June 5, 2005; effective through November 27, 2005. Public necessity rule filed November 16, 2005; effective through April 30, 2006. Original rule filed February 3, 2006; effective April 19, 2006. Amendment filed December 20, 2007; effective March 4, 2008. Amendments filed November 27, 2017; effective February 25, 2018. Administrative changes made to this chapter on September 10, 2019; "Tennessee Workers' Compensation Act" or "Act" references were changed to "Tennessee Workers' Compensation Law" or "Law." Amendments filed June 24, 2021; effective September 22, 2021. Amendments filed June 27, 2023; effective 9/25/2023.

Authority: T.C.A. §§ 50-6-204, 50-6-205, and 50-6-233 (Repl. 2005).