Section 0800-02-17-.03 - DEFINITIONSThe 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;(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;(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;(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.Tenn. Comp. R. & Regs. 0800-02-17-.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 December 20, 2007; effective March 4, 2008. Amendments filed June 12, 2009; effective August 26, 2009. Amendment filed December 26, 2013; effective March 26, 2014. Repeal and new rules 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 28, 2021; effective September 26, 2021. Amendments filed June 27, 2023; effective 9/25/2023.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).