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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
TN
TNDOI-MRF-CPT-88305
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Tennessee Department of Commerce and Insurance (TDCI) & CMS TiC Payer MRF Index
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Davidson County, TN
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Filing / IDR Window: 2026-11-25
TN Commercial Payer TiC MRF & Lab Reimbursement Cohort — CPT 88305 / 80053
Commercial payer TiC MRF negotiated rate audit, CMS Medicare MPFS RVU/GPCI locality repricing, and ERISA 29 CFR § 2560.503-1 / Federal No Surprises Act (45 CFR § 149.510) IDR arbitration package for Pathology & Clinical Laboratory in TN (CPT 88305 Level IV Surgical Pathology & Out-of-Network Lab Payer MRF Rates).
Cohort MRF 75th-Pct Value
$1,355,000
Target % of Medicare
218.5% MPFS
Statutory Authority
TN-GPCI-2026 (Tenn. Code Ann. § 56-7-109 (21% Prompt-Pay))
ERISA / Timely-Filing Window
120 Days
1. Commercial Payer TiC MRF Allowed-Amount Benchmarks (API #02)
| CPT / DRG Code | Clinical Procedure Description | Unit | Cohort Claims | MRF 25th Pct | MRF Median (QPA) | MRF 75th Pct |
|---|---|---|---|---|---|---|
| CPT-45378 | Diagnostic Colonoscopy with Biopsy (ASC Facility + Pro) | CLAIM | 420 | $373.10 | $878.15 | $1,105.65 |
| CPT-43239 | Upper GI Endoscopy (EGD) with Biopsy | CLAIM | 190 | $541.00 | $1,273.32 | $1,603.19 |
| CPT-99214-25 | Level 4 Established Patient Outpatient E/M with Separately Identifiable Modifier 25 | CLAIM | 1,200 | $115.00 | $172.00 | $204.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
American Esoteric LaboratoriesTN Regional Pathology Associates PATN Ambulatory Pathology Center LLC