Ambulatory Patient Group (APG) Regulations

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Summary of Express Terms

General Summary for 86–8.1 through 86–8.12

86–8.1 – Scope of services and effective dates

86–8.2 – Definitions

86–8.6 – Rates for new facilities during the transition period

86–8.10 Exclusions from payment

86–8.13 Out–of–State Providers

86–8.14 Non–APG Payments

SUBPART 86–8

OUTPATIENT SERVICES: AMBULATORY PATIENT GROUP

(Statutory authority: Public Health Law § 2807(2–a)(e))

Sec.

86–8.1         Scope

86–8.2         Definitions

86–8.3         Record keeping, reports and audits

86–8.4         Capital reimbursement

86–8.5         Administrative rate appeals

86–8.6         Rates for new facilities during the transition period

86–8.7         APGs and relative weights

86–8.8         Base rates

86–8.9         Diagnostic coding and rate computation

86–8.10        Exclusions from payment

86–8.11        System updating

86–8.12        Payments for extended hours of operation

86–8.13        Out–of–state providers

86–8.14        Non–APG payments

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Section 86–8.1 is amended to read as follows:

§ 86–8.1 Scope

(a) This Subpart shall govern Medicaid rates of payments for ambulatory care services provided in the following categories of facilities for the following periods:

1. outpatient services provided by general hospitals on and after December 1, 2008;
2. emergency department services provided by general hospitals on and after January 1, 2009;
3. ambulatory surgery services provided by general hospitals on and after December 1, 2008;
4. ambulatory services provided by diagnostic and treatment centers on and after [March] September 1, 2009; and
5. ambulatory surgery services provided by free–standing ambulatory surgery centers on and after [March] September 1, 2009.

(b) Notwithstanding subdivision (a) of this section, the provisions of this Subpart shall not apply to the following:

1. facilities whose Medicaid reimbursement is governed by subdivision 8 of section 2807 of the public health law, except when the provisions of this Subpart are made applicable pursuant to paragraph (f) of such subdivision;
2. payments for services which are not provided pursuant to a facility´s licensure under article 28 of the public health law;
3. payments made on behalf of persons enrolled in Medicaid managed care or in the family health plus program[; and
4. payments made to facilities located outside the boundaries of New York State].

Subdivision (g) of Section 86–8.2 is amended to read as follows:

(g) Discounting shall mean the reduction in APG payment that results when [unrelated] additional procedures [or ancillary services are performed during a single patient visit.] do not consolidate. Additional occurrences of the same ancillary APG within a single visit or episode will also discount.

Subdivision (k) of Section 86–8.2 is amended to read as follows:

(k) Packaging shall mean those circumstances in which payment for routine ancillary services or drugs shall be deemed as included in the applicable APG payment for a related significant procedure or medical visit. Medical visits also package with significant procedures, unless specifically excepted in this regulation.

Subdivision (p) of Section 86–8.2 is amended to read as follows:

(p) Visit shall mean a unit of service consisting of all the APG services performed for a patient [on] that are coded on the same claim and share a common [a single] date of service[, provided, however, that services provided in an emergency department which extend into a second calendar date may be treated as one visit for reimbursement purposes].

Section 86–8.2 is amended to add new subdivisions (p–1) and (p–2) to read as follows:

(p–1) Episode shall mean a unit of service consisting of all services on a claim, regardless of the coded dates of service. Under episode billing, an episode shall consist of all medical visits and/or procedures that are provided by a clinic to a patient on a single date of service plus any associated non–carved–out ancillaries, regardless of the date of service of those ancillaries. For emergency departments, the significant procedures and/or medical visits comprising the non–carved–out ancillary services portion of an episode need not be on a single date of services and may instead be on consecutive dates of service. Multiple episodes shall not be coded on the same claim.

(p–2) The calculation of the APG payment by the APG software may be either visit–based or episode–based depending on the rate code used to access the APG software logic. References to "visits" in this Subpart shall be deemed to refer also to "episodes" for rate–setting purposes.

Section 86–8.6 is amended to read as follows:

Section 86–8.6 Rates for new facilities during the transition period.

(a) General hospital outpatient clinics which commence operation after December 31, 2007 and prior to January 1, 2012, and for which rates computed pursuant to Public Health Law section 2807(2) are not available shall have the capital cost component of their rates based on a budget as submitted by the facility and as approved by the department and shall have the operating component of their rates computed in accordance with the following:

1. for the period December 1, 2008 through [December 31] November 30, 2009, 75% of such rates shall reflect the historical 2007 average payment per visit as calculated by the department, and 25% of such rates shall reflect APG rates as computed in accordance with this Subpart;
2. for the period [January 1, 2010] December 1, 2009 through December 31, 2010, 50% of such rates shall reflect the historical 2007 average payment per visit as calculated by the department, and 50% of such rates shall reflect APG rates as computed in accordance with this Subpart;
3. for the period January 1, 2011 through December 31, 2011, 25% of such rates shall reflect the historical 2007 average payment per visit as calculated by the department, and 75% of such rates shall reflect APG rates as computed in accordance with this Subpart;
4. for periods on and after January 1, 2012, 100% of such rates shall reflect APG rates as computed in accordance with this Subpart.
5. For the purposes of this subdivision, the historical 2007 regional average payment per visit shall mean the result of dividing the total facility specific Medicaid reimbursement paid for general hospital outpatient clinic claims paid in the 2007 calendar year in the applicable upstate or downstate region for all rate codes reflected in the APG rate–setting methodology except those specifically excluded pursuant to section 86–8.10 of this Subpart, divided by the total visits on claims paid under such rate codes.

(b) Diagnostic and treatment centers which commence operation after December 31, 2007 and prior to January 1, 2012, and for which rates computed pursuant to public health law section 2807(2) are not available shall have the capital cost component of their rates based on a budget as submitted by the facility and as approved by the Department and shall have the operating cost component of their rates computed in accordance with the following:

1. for the period [March] September 1, 2009 through [December 31] November 30, 2009, 75% of such rates shall reflect the historical 2007 regional average peer group payment per visit as calculated by the department, and 25% of such rates shall reflect APG rates as computed in accordance with this Subpart;
2. for the period [January 1, 2010] December 1, 2009 through December 31, 2010, 50% of such rates shall reflect the historical 2007 regional average peer group payment per visit as calculated by the department, and 50% of such rates shall reflect APG rates as computed in accordance with this Subpart;
3. for the period January 1, 2011 through December 31, 2011, 25% of such rates shall reflect the historical 2007 regional average peer group payment per visit as calculated by the department, and 75% of such rates shall reflect APG rates as computed in accordance with this Subpart;
4. for periods on and after January 1, 2012, 100% of such rates shall reflect APG rates as computed in accordance with this Subpart.
5. For the purposes of this subdivision, the historical 2007 regional average peer group payment per visit shall mean the result of dividing the total facility specific Medicaid reimbursement paid for diagnostic and treatment center claims for each peer group, as defined in section 86–4.13 of this Part, paid in the 2007 calendar year in the applicable upstate or downstate region for all rate codes reflected in the APG rate–setting methodology except those specifically excluded pursuant to section 86–8.10 of this Subpart, divided by the total visits on claims paid under such rate codes.

(c) Free–standing ambulatory surgery centers which commence operation after December 31, 2007 and prior to January 1, 2012, and for which rates computed pursuant to public health law section 2807(2) are not available shall have the capital cost component of their rates computed in accordance with section 86–8.4(c) of this Subpart and shall have the operating cost component of their rates computed in accordance with the following:

1. for the period [March] September 1, 2009 through [December 31] November 30, 2009, 75% of such rates shall reflect the historical 2007 regional average payment per visit as calculated by the department, and 25% of such rates shall reflect APG rates as computed in accordance with this Subpart;
2. for the period [January 1, 2010] December 1, 2009 through December 31, 2010, 50% of such rates shall reflect the historical 2007 regional average payment per visit as calculated by the department, and 50% of such rates shall reflect APG rates as computed in accordance with this Subpart;
3. for the period January 1, 2011 through December 31, 2011, 25% of such rates shall reflect the historical 2007 regional average payment per visit as calculated by the department, and 75% of such rates shall reflect APG rates as computed in accordance with this Subpart;
4. for periods on and after January 1, 2012, 100% of such rates shall reflect APG rates as computed in accordance with this Subpart.
5. For the purposes of this subdivision, the historical 2007 regional average payment per visit shall mean the result of dividing the total facility specific Medicaid reimbursement paid for free–standing ambulatory surgery centers claims paid in the 2007 calendar year in the applicable upstate or downstate region for all rate codes reflected in the APG rate–setting methodology except those specifically excluded pursuant to section 86–8.10 of this Subpart, divided by the total visits on claims paid under such rate codes.

Subdivisions (a) and (h) of section 86–8.10 of subpart 86–8 are amended to read as follows:

(a) Drugs and other pharmaceutical products and implantable family planning devices for which separate and distinct outpatient billing and payment were authorized by the Department as of December 31, 2007, and as set forth by the Department in written billing instructions issued to providers subject to this Subpart, and as may be subsequently modified by the Department, HIV counseling and testing visits, post–test HIV counseling visits (positive results), HIV counseling visit (no testing), day health care service (HIV), TB/directly observed therapy –– downstate levels 1 and 2, TB/directly observed therapy –– upstate levels 1 and 2, AIDS clinic therapeutic visits in general hospital outpatient clinics, child rehabilitation services provided under rate code 2887 in general hospital outpatient clinics, Medicaid obstetrical and maternity services (MOMS) provided under rate code 1604.

(h) The following APGs shall not be eligible for reimbursement pursuant to this Subpart:

065	RESPIRATORY THERAPY
066	PULMONARY REHABILITATION
[094	CARDIAC REHABILITATION]
117	HOME INFUSION
118	NUTRITION THERAPY
190	ARTIFICIAL FERTILIZATION
311	FULL DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE
312	FULL DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS
313	HALF DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE
314	HALF DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS
319	ACTIVITY THERAPY
320	CASE MANAGEMENT – MENTAL HEALTH OR SUBSTANCE ABUSE
371	[LEVEL I] ORTHODONTICS
[372	LEVEL II ORTHODONTICS]
427	BIOFEEDBACK AND OTHER TRAINING
430	CLASS I CHEMOTHERAPY DRUGS
431	CLASS II CHEMOTHERAPY DRUGS
432	CLASS III CHEMOTHERAPY DRUGS
433	CLASS IV CHEMOTHERAPY DRUGS
434	CLASS V CHEMOTHERAPY DRUGS
450	OBSERVATION
452	DIABETES SUPPLIES
453	MOTORIZED WHEELCHAIR
454	TPN FORMULAE
456	MOTORIZED WHEELCHAIR ACCESSORIES
492	DIRECT ADMISSION FOR OBSERVATION INDICATOR
500	DIRECT ADMISSION FOR OBSERVATION – OBSTETRICAL
501	DIRECT ADMISSION FOR OBSERVATION – OTHER DIAGNOSES
999	UNASSIGNED

Subpart 86–8 is amended by adding a new section 86–8.13, to read as follows:

§ 86–8.13 Out–of–state providers

(a) Rates for services specified in section 86–8.1(a) of this Subpart provided in outpatient facilities located outside New York state shall be as follows:

1. rates in effect for similar services for providers located in the downstate region of New York state shall apply with regard to services provided by out–of–state providers located in the New Jersey counties of Sussex, Passaic, Bergin, Hudson, Essex, Union, Middlessex and Monmouth, in the Pennsylvania county of Pike, and in the Connecticut counties of Fairfield and Litchfield; and
2. rates in effect for similar services for providers located in the upstate region of New York state shall apply with regard to all other out–of–state providers.

(b) Notwithstanding any inconsistent provision of this section, in the event the Department determines that an out–of–state provider is providing services which are not available within New York state, the Department may negotiate payment rates and conditions with such a provider. Prior approval by the Department shall be required with regard to services provided by such providers.

(c) For the purposes of this section the downstate region of New York state shall consist of the New York counties of Bronx, New York, Kings, Queens, Richmond, Nassau, Suffolk, Westchester, Rockland, Orange, Putnam and Dutchess, and the upstate region of New York state shall consist of all other New York counties.

Subpart 86–8 is amended by adding a new section 86–8.14, to read as follows:

§ 86–8.14 Non–APG payments

(a) Psychotherapy services by clinical social workers. To the extent authorized pursuant to section 2807(2–a) of the Public Health Law, payments for individual psychotherapy services provided by clinical social workers, as defined by section 86–4–9 of this Subpart, shall be established at $40.64 for encounters lasting between twenty and thirty minutes and at $62.33 for encounters lasting between forty–five and fifty minutes and at $69.93 for family therapy encounters lasting between forty–five and fifty minutes.

(b) Wheelchair evaluation services. Payments for comprehensive wheelchair evaluations, which shall include assessments, fittings and training consisting of at least two hours of direct patient care services, shall be established at $302.

(c) Eyeglasses dispensing. Payments for dispensing eyeglasses shall be established at $89.77, plus capital, when such service includes the cost of providing the eyeglasses and at $38.05, plus capital, when such service does not include the cost of providing the eyeglasses. The capital add–on per visit for each provider shall be the provider´s capital add–on per visit as otherwise calculated pursuant to applicable provisions of section 2807(2) of the Public Health Law.

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REGULATORY IMPACT STATEMENT

Statutory Authority:

Legislative Objective:

Needs and Benefits:

COSTS

Costs for the Implementation of, and Continuing Compliance with this Regulation to the Regulated Entity:

Costs to Local Governments:

Costs to State Governments:

Costs to the Department of Health:

Local Government Mandates:

Paperwork:

Duplication:

Alternatives:

Federal Standards:

Compliance Schedule:

Contact Person:
Ms. Katherine Ceroalo
New York State Department of Health
Bureau of House Counsel, Regulatory Affairs Unit Corning
Tower Building, Rm. 2438
Empire State Plaza
Albany, New York 12237
(518) 473–7488
(518) 473–2019 (FAX)
REGSQNA@health.ny.gov

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REGULATORY FLEXIBILITY ANALYSIS FOR SMALL BUSINESS AND LOCAL GOVERNMENTS

Effect on Small Business and Local Governments:

Compliance Requirements:

Professional Services:

Economic and Technical Feasibility:

Compliance Costs:

Minimizing Adverse Impact:

Small Business and Local Government Participation:

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RURAL AREA FLEXIBILITY ANALYSIS

Effect on Rural Areas:

Allegany	Hamilton	Schenectady
Cattaraugus	Herkimer	Schoharie
Cayuga	Jefferson	Schuyler
Chautauqua	Lewis	Seneca
Chemung	Livingston	Steuben
Chenango	Madison	Sullivan
Clinton	Montgomery	Tioga
Columbia	Ontario	Tompkins
Cortland	Orleans	Ulster
Delaware	Oswego	Warren
Essex	Otsego	Washington
Franklin	Putnam	Wayne
Fulton	Rensselaer	Wyoming
Genesee	St. Lawrence	Yates
Greene	Saratoga

Albany	Erie	Oneida
Broome	Monroe	Onondaga
Dutchess	Niagara	Orange

Compliance Requirements:

Professional Services:

Compliance Costs:

Minimizing Adverse Impact:

Opportunity for Rural Area Participation:

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JOB IMPACT STATEMENT

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