Tennessee's Medical Fee Schedule
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 law, no matter where the injury took place. Unlike fee schedules in some other states, Tennessee’s Medical Fee Schedule does not set an absolute fee for services, but instead, sets a maximum amount that may be paid.
What is covered by the 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 maximum amount. If there is no specific methodology in the Rules for reimbursement, the maximum reimbursement is 100% of Medicare. Whenever there is not Medicare methodology, maximum reimbursement is Usual & Customary or U & C (80% of billed charges).
Chapter 0800-2-17, is called the Medical Cost Containment Program Rules. This part contains general information applicable to the other two chapters, including most of the definitions used throughout all three chapters, as well as the purpose, scope, general guidelines and procedures. This chapter also 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.
Most definitions needed for proper use of the Tennessee Medical Fee Schedule are provided in the Medical Cost Containment Program Rules, specifically Rule 0800-2-17-.03. These should be consulted thoroughly to familiarize you with the particular meanings of terms used throughout the Medical Fee Schedule and in the Inpatient Hospital Fee Schedule.
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.
Chapter 0800-2-18, is the actual Medical Fee Schedule Rules and addresses the proper conversion factors 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 certain types of medical devices and equipment (such as durable medical equipment and prosthetics and orthotics), the maximum allowable amounts for ambulatory surgical centers (ASC’s) and hospital outpatient services, penalties for violations of the Medical Fee Schedule, and what actually constitutes a violation.
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