(Work RVU * work GPCI ) + (transitioned facility PE RVU * PE GPCI) + (MP RVU * MP GPCI) = Total RVU’s * Medicare Conversion Factor * TN specific Conversion Factor = Payment
If you have no idea what the above equation is – join the crowd. If you know what it is, but don’t know what it means, or how to use it, you’re in the majority of Tennessee’s employers and health care providers. This equation is the formula utilized to determine the Tennessee Workers’ Compensation Fee Schedule. The following is an example of how to utilize the equation taken from the 2011 Tennessee Work Comp Fee Book, which is published by the Tennessee Department of Labor and Workforce Development (TNDOL):
Example: CPT code 25444 ---Reconstruct wrist joint – 100% of Tennessee Medicare is 752.73 The maximum allowable for Tennessee is 752.73 x 2.242 (200% of TN Medicare using the 38.0870 conversion amount from March 2008) = 1687.62 (unless the surgeon is a board-certified or board-eligible neurosurgeon or orthopedic surgeon, in which case the maximum allowable is 275% of Tennessee Medicare using the 38.0870 conversion amount from March 2008 which = 2320.44. This is calculated by the following: (work RVU 11.42 * work GPCI 1.000) = 11.42 + (transitioned facility PE RVU 10.88 * PE GPCI 0.945) =10.282 + (MP RVU 0.80 * MP GPCI 0.566) = 0.4528 = Total RVU’s = 22.1548 * Medicare 33.9764 = 752.73 * 2.242 Surgery = 1687.62 Total RVU’s = 22.1548 * Medicare 33.9764 = 752.73 * 3.0827 Bd Cert Surgery= 2320.44
Currently, the TNDOL does not publish an actually fee schedule but gives multiple examples like the one above to assist employers, healthcare providers, and insurance carriers to determine proper reimbursement for the ~ 15,000+ CMS codes.
Still scratching your head? Again you’re not alone. RVU’s and conversion factors change yearly and the complexity of the formula and code variations can be confusing at best.
LET SUNESIS MEDICAL HELP!
If knowledge is power; let us empower you with a spreadsheet based program that will allow you to simply enter a code, and determine the proper reimbursement for physician office visits, surgical procedures, therapy, radiology, and chiropractics. In today’s competitive global economy, employers need to know cost down to the last rivet, but how many employers know what a rotator cuff repair surgery will cost? Knowing this fundamental cost will bring transparency to the process between the employer, the insurance carrier (including bill review), and the healthcare provider. All of these aspects will affect your bottom line.
NOT JUST FOR EMPLOYERS!
Proper reimbursement for care is also necessary, and just as complicated, for Tennessee’s health care providers. For Tennessee’s providers, the same spreadsheet based program should become a vital part of your bill review and payment posting process.
Sunesis can custom create a package for employers; including but not limited to:
- Tennessee Workers’ Compensation Fee Schedule on an easy to use spreadsheet – includes instruction on use.
- Work Comp 101 – onsite instruction to dedicated personal on the use of the spreadsheet, and a basic course on workers’ compensation.
- EOB Review and Audit
- Administrative Charge Audit
- Chart Review
- Information about TNDOL Rules changes, Legislative Bills, and Laws (free on our web-site)
Please feel free to contact us regarding your specific needs.