Section 0800-02-17-.05 - PROCEDURE CODES, ADOPTION OF THE CMS MEDICARE PROCEDURES, GUIDELINES, AND AMOUNTS, RATE TABLES(1) Services and medical supplies shall be coded with valid procedure or supply codes of the Healthcare Common Procedure Coding System ("HCPCS"). Level I HCPCS procedure codes (CPT® codes) used in these Rules were developed and copyrighted by the American Medical Association ("AMA"). Level II HCPCS procedure codes used in these Rules were developed by CMS.(2) The editions adopted by CMS of the American Medical Association's Current Procedural Terminology ("CPT®"), the Medicare MS-DRG table, the Medicare RBRVS in effect on the date of service or date of discharge, and the National Correct Coding Initiative edits ("NCCI") are incorporated in these Rules and shall be used in conjunction with these Rules. NCCI also includes Medically Unlikely Edits ("MUE") that identify a maximum number of units allowable under most circumstances for a single HCPCS or CPT® code billed on a date of service for a single patient. For more information, see https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index and https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.(3) Unless otherwise explicitly stated in these Rules, the Medicare procedures and guidelines in effect on the date of service are hereby adopted and incorporated as part of these Rules as if fully set out herein and are effective upon adoption and implementation by Medicare.(4) Whenever there is no specific fee or methodology for reimbursement set forth in these Rules and rate tables, then the maximum amount of reimbursement shall be at 100% of the Medicare allowable amount. The Medicare guidelines and procedures in effect on the date of service shall be followed in arriving at the correct amount, subject to the requirements of Rule 0800-02-18-.02(4). The Medical Fee Schedule conversion factor and TN specific conversion percentages may be, upon review by the Administrator, adjusted periodically. If there is no Medicare allowable amount, the service shall be reimbursed at the usual and customary amount as defined in Rule 0800-02-17-.03 of this chapter.(5) Telehealth: the definitions, licensing and processes for the purpose of these Rules shall be the same as adopted by the Tennessee Department of Health and Medicare. The maximum reimbursement for services provided via telehealth is the lesser of billed charges or the amounts listed in this fee schedule. Services that are eligible to be provided via telehealth are identified with a star (STAR) in the rate tables.(6) The fee schedule, including rate tables, will be available free of charge in a standard downloadable format (pdf/excel) from a link provided on the bureau's website.Tenn. Comp. R. & Regs. 0800-02-17-.05
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. 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, 50-6-204, 50-6-205, 50-6-226, and 50-6-233 (Repl. 2005) and Public Chapters 282 & 289 (2013).