(1) This section defines the reimbursement
procedures and calculations for inpatient health care services by all
hospitals.
Hospital reimbursement is divided into four (4) groups based on type
of admission:
(a) Peer Groups:
1. Peer Group 1-surgical or non-surgical
(medical);
2. Peer Group
2-rehabilitation;
3. Peer Group
3-psychiatric;
4. Peer Group
4-trauma, level 1 and:
(b) Length of stay (less than eight (8)
days/over seven (7) days).
(2) General Information, Payments
For
each inpatient claim submitted, the provider shall assign a Diagnosis Related
Group (MS-DRG) code which appropriately reflects the patient's primary cause
for hospitalization to determine average length of stay and for tracking
purposes. Hospitals within each peer group are to be paid the maximum amount
per inpatient day unless a contracted rate is less. An additional payment will
be due if the total bill for the hospitalization exceeds the stop loss
threshold as defined below.
(a) The
maximum per diem rates to be used in calculating the reimbursement rate is as
follows:
1. Peer
Group 1
|
$2,347 (surgical admission) daily
for the first seven (7) days;
|
|
$2,032 (surgical admission) per day for the 8th day and
thereafter;
|
|
Note: these rates include Intensive Care (ICU) & Critical and Cardiac
Care (CCU) if not a trauma admission as defined above.
|
|
$1,932 (medical admission)
daily for first seven (7) days;
|
|
$1,670 (medical admission) per day for the 8th day and
thereafter;
|
|
Note: these rates include Intensive Care (ICU) & Critical and Cardiac
Care (CCU).
|
2. Peer Group 2
(Rehabilitation)
|
$1,145 for the first
seven (7) days and $935 per day thereafter.
|
3. Peer Group 3 (Psychiatric)
|
$830 per day (applicable also to chemical
dependency).
|
4. Peer Group 4
(Trauma level 1)
|
All trauma care at any
licensed Level 1 Trauma Center only shall be reimbursed at a maximum rate of
$4,725 per day for each day of the patient's admission as defined in
0800-02-18-.02(16).
|
(b) Surgical implants shall be reimbursed
separately and in addition to the per diem hospital charges.
(c) Reimbursement for trauma inpatient
hospital services shall be limited to the lesser of the maximum allowable as
calculated by the appropriate per diem rate, or the hospital's billed charges
minus any non-covered charges. Non-covered charges are convenience items or
charges for services not related to the work injury/illness.
(d) Additional reimbursement may be made in
addition to the per diem for implantables (i.e. rods, pins, plates and joint
replacements, etc.). Reimbursement for implantables is limited to a maximum of
the hospital's cost plus fifteen percent (15%)-capped at one thousand dollars
($1000)-of the original manufacturer's invoice amount. This is applicable per
item and is not cumulative. Implantables shall be billed using the appropriate
HCPCS codes when available. Billing for implantables shall be accompanied by an
invoice.
(e) The following items
are not included in the per diem reimbursement to the facility and may be
reimbursed separately. All of these items shall be listed with the applicable
CPT®/HCPCS code.
1. Durable Medical
Equipment;
2. Orthotics and
Prosthetics;
3.
Implantables;
4. Ambulance
Services;
5. Take home medications
and supplies.
(f) The
items listed in subsection (e) shall be reimbursed according to the Rules for
Medical Payments (Chapter 0800-02-17), and the Medical Fee Schedule Rules
(Chapter 0800-02-18) payment limits. Refer to the maximum rates set forth in
Rule 0800-02-18 for practitioner fees. Items not listed in the Rules shall be
reimbursed at the usual and customary rate as defined in Rule 0800-02-17,
unless otherwise indicated herein.
(g) Per-diem rates are all inclusive (with
the exception of those items listed in subparagrah (e) above).
(h) The Inpatient Hospital Fee Schedule
allows for independent reimbursement on a case-by-case basis if the particular
care exceeds the Stop-Loss Threshold.
(i) Payments for implantables shall be made
only to the facility and not to a supplier or distributor.
(j) Charges for licensed/accredited Skilled
Nursing Facilities shall be paid according to the CMS national unadjusted rates
for urban or rural facilities in effect on the date of service, applicable
carve outs, including adjustments made under "Patient-Drive Payment Model"
(PDPM) or later CMS methodology. The bill shall include the applicable
"Resource Utilization Group" (RUG) for each day. Hospital per-diem and stop
loss calculations do not apply to these facilities.
(3) Reimbursement Calculations
(a) Explanation
1. Each admission is assigned an appropriate
MS-DRG.
2. The applicable Standard
Per Diem Amount ("SPDA") is multiplied by the length of stay ("LOS") for that
admission plus items listed under (e) above:
Formula: (LOS) x (SPDA) +
(items listed under (e) above)=WCRA
3. The Workers' Compensation Reimbursement
Amount ("WCRA") is the total amount of reimbursement to be made for that
particular admission and may include a stop loss payment ("SLP") as calculated
below.
(4)
Stop-Loss Method
(a) Stop-loss is an
independent reimbursement factor established to ensure fair and reasonable
compensation to the hospital for services rendered during treatment to an
injured worker. This stop-loss threshold is established to ensure compensation
for services required during an admission.
(b) Explanation
1. To be eligible for stop loss payment, the
total
Allowed Charges for a
hospital admission shall exceed the
hospital
maximum payment, as determined by the
hospital maximum payment rate per day, by
at least $21,788 for Non-Trauma Admissions and $31,500 for Trauma Admissions.
This does not include amounts for items set forth in rule
0800-02-19-.03, such as
implantables, DME, etc., which shall not be included in determining the total
Allowed Charges for stop-loss calculations.
2. Once the allowed charges reach the
stop-loss threshold, reimbursement for all additional charges shall be made
based on a stop-loss payment factor of 80%.
3. The additional charges are multiplied by
the Stop-Loss Reimbursement Factor (SLRF) and added to the maximum allowable
payment.
(c) Formula:
(LOS) x (SPDA) + (Items listed under (2)(e) in this section) + (Additional
Charges x SLRF)=WCRA
(5)
Billing for Inpatient Admissions
(a) All
bills for inpatient institutional services shall be submitted on the standard
billing form or any revision to that form approved for use by the
Medicare.
Notes
Tenn. Comp. R. & Regs. 0800-02-19-.03
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
June 12, 2009; effective August 26, 2009. Amendments filed March 12, 2012; to
have been effective June 10, 2012. The Government Operations Committee filed a
stay on May 7, 2012; new effective date August 9, 2012. Amendments filed
November 27, 2017; effective February 25, 2018. Amendments filed June 12, 2019;
effective September 10, 2019. 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 27, 2023; effective 9/25/2023.
Authority: T.C.A. §§
50-6-125,
50-6-128,
50-6-204, and
50-6-205 (Repl. 2005).