Medical Fee Schedulefor Workers' Compensation in Tennessee
The Tennessee Workers’ Compensation Medical Fee Schedule (MFS) applies to all medical services and medical equipment or supplies and is applicable to all injured employees claiming workers’ compensation benefits under Tennessee’s Workers’ Compensation Act. This Medical Fee Schedule does not set an absolute fee for services, but instead, sets a maximum amount that may be paid unless a waiver is granted by the Bureau.
What is covered by the Medical Fee Schedule?
The Medical Fee Schedule is made-up of three (3) parts of administrative rules, called Chapters, and has undergone several revisions since the first version became effective on July 1, 2005. Payments are based on the date the medical service is received, not on the date of the employee’s injury. Providers and payers are encouraged to negotiate amounts below the maximum set in the Medical Fee Schedule, but shall not pay an amount above the Fee Schedule’s maximum amount except when a waiver is granted by the Bureau. If there are no specific criteria in the Rules for reimbursement and there is a Medicare code and price, the maximum reimbursement is 100% of Medicare. Whenever there is no Medicare methodology, code or price, the maximum reimbursement is Usual & Customary which is defined as 80% of billed charges.
- Chapter 0800-02-17, Rules for Medical Payments, contains general information applicable to the other two chapters, including the definitions used throughout all three chapters, the purpose, scope, general guidelines and procedures. This chapter explains the basis for the Medical Fee Schedule (Medicare for most of the Medical Fee Schedule), the time-period payers have to timely reimburse providers for undisputed bills, what happens if payers do not comply, and appeal procedures.
- Chapter 0800-02-18 addresses the proper conversion factor and specific conversion percentage to use for calculating the maximum allowable amounts for physicians’ professional services (determined by the classification of the CPT® codes), the maximum allowable amounts that may be paid for medical devices and equipment, durable medical equipment, prosthetics and orthotics, r ambulatory surgical centers (ASC’s) and hospital outpatient services. Penalties for violations of the Medical Fee Schedule and the definition of a violation are explained.
- Chapter 0800-02-19 is the inpatient fee schedule. Hospital inpatient services are paid by a daily rate (per-diem) and include a stop-loss method for additional payments for unusually severe injuries. Payments vary according to the peer group and the type of admission.
o Relative Value Units (“RVUs”) may be obtained from the current edition of the Medicare RBRVS: The Physician’s Guide. This should be used in conjunction with the current edition of the AMA’s CPT® Coding Guide. These books may be obtained by contacting the American Medical Association at American Medical Association, 515 N. State Street Chicago, IL 60610, telephone (800) 621-8335, or by visiting the AMA’s bookstore online at the American Medical Association’s website: www.ama-assn.org. HCPCS and ICD-10 codes may also be purchased from the AMA. Additional information on these codes may be found at www.cms.gov.
- The Medical Fee Schedule Handbook includes calculation examples for reference.
- Since the payable amounts are dependent on the date of service, questions concerning which set of Rules to follow may be directed to: UR.Appeals@tn.gov.
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