Ambulatory Patient Group (APG) Regulations
- APG Regulations also available in Portable Document Format (PDF)
Summary of Express Terms
General Summary for amendments to 86–8.2, 86–8.7, 86–8.9 and 86–8.10
The amendments to Part 86 of Title 10 (Health) NYCRR are required to update the Ambulatory Patient Groups (APGs) methodology, implemented on December 1, 2008, which governs reimbursement for certain ambulatory care fee–for–service (FFS) Medicaid services. APGs group procedures and medical visits that share similar characteristics and resource utilization patterns so as to pay for services based on relative intensity.
86–8.2 – Definitions
The proposed amendments to section 86–8.2 of Title 10 (Health) NYCRR provide an amended subdivision (c) defining procedure–based APG weights and a new subdivision (u) defining no blend APGs.
86–8.7 – APGs and relative weights
The proposed revision to section 86–8.7 of Title 10 (Health) NYCRR provides revised APG weights and also sets forth procedure–based weights to be used under APG reimbursement.
86–8.9 – Diagnostic coding and rate computation
The proposed amendments to section 86–8.9 removes the restriction on allowing a capital add–on for ancillary–only visits and replaces that with a list of APGs with which a capital add–on will not be allowed, specifically: 94 Cardiac Rehabilitation; 274 Physical Therapy, Group; 275 Speech Therapy and Evaluation, Group; 322 Medication Administration and Observation; 414 Level I Immunization and Allergy Immunotherapy; 415 Level II Immunization; 416 Level III
Immunization; 428 Patient Education, Individual; 429 Patient Education, Group. The list of no blend APGs is also provided, those being: 94 Cardiac Rehabilitation; 310 Developmental and Neuropsychological Testing; 312 Full Day Partial Hospitalization for Mental Illness; 321 Crisis Intervention; 322 Medication Administration and Observation; 414 Level I Immunization and Allergy Immunotherapy; 415 Level II Immunization; 416 Level III Immunization; 426 Medication Management; 428 Patient Education, Individual; 429 Patient Education, Group; 448 After Hours Services; 451 Smoking Cessation Treatment.
86–8.10 Exclusions from Payment
The proposed amendments removes 118 Nutrition Therapy from the "never pay" APG list set forth in subdivision (h) and places it on the "if stand alone do not pay" list set forth in subdivision (i). The following additional APGs are added to the never pay APG list; 441 Class VI Chemotherapy Drugs; 442 Class VII Combined Chemotherapy and Pharmacotherapy. The following additional APGs are added to the if stand alone do not pay list: 281 Magnetic Resonance Angiography – Head and/or Neck; 282 Magnetic Resonance Angiography – Chest; 283 Magnetic Resonance Angiography – Other Sites; 292 MRI – Abdomen; 293 MRI – Joints; 294 MRI – Back; 295 MRI – Chest; 296 MRI – Other; 297 MRI – Brain; 373 Level I Dental Film; 374 Level II Dental Film; 375 Dental Anesthesia; 440 Class VI Pharmacotherapy.
Pursuant to the authority vested in the Commissioner of Health by sections 2807(2–a)(e) of the Public Health Law, section 79(u) of part C of chapter 58 of the laws of 2008 and section 129(l) of part C of chapter 58 of the laws of 2009, Subpart 86–8 of Title 10 (Health) of the Official Compilation of Codes, Rules and Regulations of the State of New York is hereby amended, to be effective upon filing with the Department of State, and to read as follows:
Subdivision (c) of section 86–8.2 is amended, and a new subdivision (u) of section 86–8.2 is added, to read as follows:
(c) APG relative weight shall mean a numeric value that reflects the relative expected average resource utilization (cost) for each APG as compared to the expected average resource utilization for all other APGs. Procedure–based APG weight shall mean a numeric value that reflects the relative expected average resource utilization (cost) for a specific procedure. A procedure that has been assigned its own weight shall have its payment derived from its procedure–specific weight without regard to the weight of the APG to which the procedure groups.
(u) No blend APG shall mean an APG that has its entire payment calculated under the APG reimbursement methodology without regard to the 2007 historical average operating payment per visit for the provider.
Section 86–8.7 is repealed and a new section 86–8.7 is added to read as follows:
Section 86–8.7 APGs and relative weights
- The APGs and each associated relative weight are:
January 2010 APG WeightsAPG APG Description Weight 1 PHOTOCHEMOTHERAPY 0.6402 2 SUPERFICIAL NEEDLE BIOPSY AND ASPIRATION 3.2448 3 LEVEL I SKIN INCISION AND DRAINAGE 1.8962 4 LEVEL II SKIN INCISION AND DRAINAGE 2.7968 5 NAIL PROCEDURES 0.7008 6 LEVEL I SKIN DEBRIDEMENT AND DESTRUCTION 1.3672 7 LEVEL II SKIN DEBRIDEMENT AND DESTRUCTION 2.6624 8 LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION 3.9132 9 LEVEL I EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 3.6788 10 LEVEL II EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 4.6370 11 LEVEL III EXCISION AND BIOPSY OF SKIN AND SOFT TISSUE 7.9567 12 LEVEL I SKIN REPAIR 0.4352 13 LEVEL II SKIN REPAIR 3.1648 14 LEVEL III SKIN REPAIR 5.6896 15 LEVEL IV SKIN REPAIR 6.6746 20 LEVEL I BREAST PROCEDURES 5.7790 21 LEVEL II BREAST PROCEDURES 7.4250 22 LEVEL III BREAST PROCEDURES 8.2280 30 LEVEL I MUSCULOSKELETAL PROCEDURES EXCLUDING HAND AND FOOT 6.7781 31 LEVEL II MUSCULOSKELETAL PROCEDURES EXCLUDING HAND AND FOOT 7.3495 32 LEVEL III MUSCULOSKELETAL PROCEDURES EXCLUDING HAND AND FOOT 8.8413 33 LEVEL I HAND PROCEDURES 5.4577 34 LEVEL II HAND PROCEDURES 7.5820 35 LEVEL I FOOT PROCEDURES 6.4428 36 LEVEL II FOOT PROCEDURES 6.9384 37 LEVEL I ARTHROSCOPY 10.3002 38 LEVEL II ARTHROSCOPY 26.6662 39 REPLACEMENT OF CAST 1.3745 40 SPLINT, STRAPPING AND CAST REMOVAL 0.9264 41 CLOSED TREATMENT FX & DISLOCATION OF FINGER, TOE & TRUNK 1.3420 42 CLOSED TREATMENT FX & DISLOCATION EXC FINGER, TOE & TRUNK 1.3734 43 OPEN OR PERCUTANEOUS TREATMENT OF FRACTURES 10.6160 44 BONE OR JOINT MANIPULATION UNDER ANESTHESIA 2.8085 45 BUNION PROCEDURE 9.6670 46 LEVEL I ARTHROPLASTY 6.4879 47 LEVEL II ARTHROPLASTY 7.9149 48 HAND AND FOOT TENOTOMY 4.5256 49 ARTHROCENTESIS AND LIGAMENT OR TENDON INJECTION 1.7976 60 PULMONARY TESTS 0.9756 61 NEEDLE AND CATHETER BIOPSY, ASPIRATION, LAVAGE AND INTUBATION 3.8018 62 LEVEL I ENDOSCOPY OF THE UPPER AIRWAY 1.6063 63 LEVEL II ENDOSCOPY OF THE UPPER AIRWAY 7.0115 64 ENDOSCOPY OF THE LOWER AIRWAY 6.9414 65 RESPIRATORY THERAPY 0.0000 66 PULMONARY REHABILITATION 0.0000 67 VENTILATION ASSISTANCE AND MANAGEMENT 0.9890 80 EXERCISE TOLERANCE TESTS 0.9157 81 ECHOCARDIOGRAPHY 1.6428 82 CARDIAC ELECTROPHYSIOLOGIC TESTS 5.0790 83 PLACEMENT OF TRANSVENOUS CATHETERS 8.0168 84 DIAGNOSTIC CARDIAC CATHETERIZATION 10.8688 85 ANGIOPLASTY AND TRANSCATHETER PROCEDURES 14.1670 86 PACEMAKER INSERTION AND REPLACEMENT 32.3317 87 REMOVAL AND REVISION OF PACEMAKER AND VASCULAR DEVICE 8.0808 88 LEVEL I CARDIOTHORACIC PROCEDURES 6.5873 89 LEVEL II CARDIOTHORACIC PROCEDURES 14.0707 90 SECONDARY VARICOSE VEINS AND VASCULAR INJECTION 5.8693 91 VASCULAR LIGATION AND RECONSTRUCTION 9.9140 92 RESUSCITATION 1.2138 93 CARDIOVERSION 2.5540 94 CARDIAC REHABILITATION 0.2075 95 THROMBOLYSIS 1.3001 96 ATRIAL AND VENTRICULAR RECORDING AND PACING 5.5577 97 AICD IMPLANT 66.2866 110 PHARMACOTHERAPY BY EXTENDED INFUSION 2.7427 111 PHARMACOTHERAPY EXCEPT BY EXTENDED INFUSION 1.7078 112 PHLEBOTOMY 0.7423 113 LEVEL I BLOOD AND BLOOD PRODUCT EXCHANGE 2.5089 114 LEVEL II BLOOD AND BLOOD PRODUCT EXCHANGE 7.6143 115 DEEP LYMPH STRUCTURE AND THYROID PROCEDURES 4.9538 116 ALLERGY TESTS 1.3107 117 HOME INFUSION 0.0000 118 NUTRITION THERAPY 0.0000 130 ALIMENTARY TESTS AND SIMPLE TUBE PLACEMENT 2.6993 131 ESOPHAGEAL DILATION WITHOUT ENDOSCOPY 2.7583 132 ANOSCOPY WITH BIOPSY AND DIAGNOSTIC PROCTOSIGMOIDOSCOPY 2.0351 133 PROCTOSIGMOIDOSCOPY WITH EXCISION OR BIOPSY 4.1000 135 DIAGNOSTIC UPPER GI ENDOSCOPY OR INTUBATION 4.0352 136 THERAPEUTIC UPPER GI ENDOSCOPY OR INTUBATION 5.4853 137 DIAGNOSTIC LOWER GASTROINTESTINAL ENDOSCOPY 4.1844 137 THERAPEUTIC COLONOSCOPY 4.5928 138 ERCP AND MISCELLANEOUS GI ENDOSCOPY PROCEDURES 6.4631 139 LEVEL I HERNIA REPAIR 12.4526 140 LEVEL II HERNIA REPAIR 12.4526 141 LEVEL I ANAL AND RECTAL PROCEDURES 3.8551 142 LEVEL II ANAL AND RECTAL PROCEDURES 9.7035 143 LEVEL I GASTROINTESTINAL PROCEDURES 5.2580 144 LEVEL II GASTROINTESTINAL PROCEDURES 5.7503 145 LEVEL I LAPAROSCOPY 7.0638 146 LEVEL II LAPAROSCOPY 9.8872 147 LEVEL III LAPAROSCOPY 12.0727 148 LEVEL IV LAPAROSCOPY 17.5662 160 EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY 14.2444 161 URINARY STUDIES AND PROCEDURES 1.8084 162 URINARY CATHETERIZATION AND DILATATION 0.9654 163 LEVEL I BLADDER AND KIDNEY PROCEDURES 3.7694 164 LEVEL II BLADDER AND KIDNEY PROCEDURES 6.3523 165 LEVEL III BLADDER AND KIDNEY PROCEDURES 9.0051 166 LEVEL I URETHRA AND PROSTATE PROCEDURES 5.8862 167 LEVEL II URETHRA AND PROSTATE PROCEDURES 7.4458 168 HEMODIALYSIS 1.1155 169 PERITONEAL DIALYSIS 0.4795 180 TESTICULAR AND EPIDIDYMAL PROCEDURES 7.2405 181 CIRCUMCISION 4.3799 182 INSERTION OF PENILE PROSTHESIS 19.8701 183 LEVEL I PENILE AND PROSTATE PROCEDURES 7.4393 184 LEVEL II PENILE AND PROSTATE PROCEDURES 11.0816 185 PROSTATE NEEDLE AND PUNCH BIOPSY 4.4243 190 ARTIFICIAL FERTILIZATION 0.0000 191 LEVEL I FETAL PROCEDURES 0.6073 192 LEVEL II FETAL PROCEDURES 1.1036 193 TREATMENT OF INCOMPLETE ABORTION 5.0348 194 THERAPEUTIC ABORTION 4.0229 195 VAGINAL DELIVERY 9.1031 196 LEVEL I FEMALE REPRODUCTIVE PROCEDURES 2.2269 197 LEVEL II FEMALE REPRODUCTIVE PROCEDURE 5.2127 198 LEVEL III FEMALE REPRODUCTIVE PROCEDURES 8.4636 199 DILATION AND CURETTAGE 4.9685 200 HYSTEROSCOPY 6.7490 201 COLPOSCOPY 1.4842 210 EXTENDED EEG STUDIES 1.8041 211 ELECTROENCEPHALOGRAM 1.0161 212 ELECTROCONVULSIVE THERAPY 1.5803 213 NERVE AND MUSCLE TESTS 0.7067 214 NERVOUS SYSTEM INJECTIONS, STIMULATIONS OR CRANIAL TAP 4.5475 215 LEVEL I REVISION OR REMOVAL OF NEUROLOGICAL DEVICE 25.5981 216 LEVEL II REVISION OR REMOVAL OF NEUROLOGICAL DEVICE 29.0071 217 LEVEL I NERVE PROCEDURES 8.5920 218 LEVEL II NERVE PROCEDURES 60.4926 219 SPINAL TAP 2.4132 220 INJECTION OF ANESTHETIC AND NEUROLYTIC AGENTS 3.5031 221 LAMINOTOMY AND LAMINECTOMY 8.3188 222 SLEEP STUDIES 4.5940 230 MINOR OPHTHALMOLOGICAL TESTS AND PROCEDURES 1.0119 231 FITTING OF CONTACT LENSES 0.6585 232 LASER EYE PROCEDURES 3.7703 233 CATARACT PROCEDURES 9.7756 234 LEVEL I ANTERIOR SEGMENT EYE PROCEDURES 4.3076 235 LEVEL II ANTERIOR SEGMENT EYE PROCEDURES 9.3164 236 LEVEL III ANTERIOR SEGMENT EYE PROCEDURES 11.3184 237 LEVEL I POSTERIOR SEGMENT EYE PROCEDURES 3.3451 238 LEVEL II POSTERIOR SEGMENT EYE PROCEDURES 11.7830 239 STRABISMUS AND MUSCLE EYE PROCEDURES 6.9180 240 LEVEL I REPAIR AND PLASTIC PROCEDURES OF EYE 3.2368 241 LEVEL II REPAIR AND PLASTIC PROCEDURES OF EYE 8.7718 250 COCHLEAR DEVICE IMPLANTATION 130.1036 251 OTORHINOLARYNGOLOGIC FUNCTION TESTS 0.6581 252 LEVEL I FACIAL AND ENT PROCEDURES 3.6978 253 LEVEL II FACIAL AND ENT PROCEDURES 5.4026 254 LEVEL III FACIAL AND ENT PROCEDURES 9.1044 255 LEVEL IV FACIAL AND ENT PROCEDURES 10.5997 256 TONSIL AND ADENOID PROCEDURES 5.8818 257 AUDIOMETRY 0.4211 270 OCCUPATIONAL THERAPY 0.7241 271 PHYSICAL THERAPY 0.6827 272 SPEECH THERAPY AND EVALUATION 0.6620 273 MANIPULATION THERAPY 0.2765 274 PHYSICAL THERAPY, GROUP 0.2414 275 SPEECH THERAPY & EVALUATION, GROUP 0.1931 280 VASCULAR RADIOLOGY EXCEPT VENOGRAPHY OF EXTREMITY 3.5374 281 MAGNETIC RESONANCE ANGIOGRAPHY – HEAD AND/OR NECK 3.0749 282 MAGNETIC RESONANCE ANGIOGRAPHY – CHEST 3.3887 283 MAGNETIC RESONANCE ANGIOGRAPHY – OTHER SITES 3.1315 284 MYELOGRAPHY 7.7060 285 MISCELLANEOUS RADIOLOGICAL PROCEDURES WITH CONTRAST 1.5734 286 MAMMOGRAPHY 0.6181 287 DIGESTIVE RADIOLOGY 0.8985 288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR 0.7609 289 VASCULAR DIAGNOSTIC ULTRASOUND OF LOWER EXTREMITIES 3.8860 290 PET SCANS 7.4321 291 BONE DENSITOMETRY 0.8629 292 MRI– ABDOMEN 3.1044 293 MRI– JOINTS 2.7686 294 MRI– BACK 2.6167 295 MRI– CHEST 3.0422 296 MRI– OTHER 3.3155 297 MRI– BRAIN 3.0822 298 CAT SCAN BACK 1.3976 299 CAT SCAN – BRAIN 1.1525 300 CAT SCAN – ABDOMEN 1.3393 301 CAT SCAN – OTHER 1.4662 302 ANGIOGRAPHY, OTHER 1.6385 303 ANGIOGRAPHY, CEREBRAL 1.9762 310 DEVELOPMENTAL & NEUROPSYCHOLOGICAL TESTING 0.8275 311 FULL DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE 0.0000 312 FULL DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS 0.0000 314 HALF DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS 0.0000 315 COUNSELLING OR INDIVIDUAL BRIEF PSYCHOTHERAPY 0.6206 316 INDIVIDUAL COMPREHENSIVE PSYCHOTHERAPY 0.8275 317 FAMILY PSYCHOTHERAPY 0.6206 318 GROUP PSYCHOTHERAPY 0.3207 319 ACTIVITY THERAPY 0.0000 320 CASE MANAGEMENT & TREATMENT PLAN DEVELOPMENT – MH OR SA 0.0000 321 CRISIS INTERVENTION 0.8275 322 MEDICATION ADMINISTRATION & OBSERVATION 0.1483 323 MENTAL HYGIENE ASSESSMENT 1.0344 324 MENTAL HYGIENE SCREENING & BRIEF ASSESSMENT 0.2803 330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE 1.6002 331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE 1.9801 332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE 3.0866 340 THERAPEUTIC NUCLEAR MEDICINE 1.1710 341 RADIATION THERAPY AND HYPERTHERMIA 1.2696 342 AFTERLOADING BRACHYTHERAPY 6.2542 343 RADIATION TREATMENT DELIVERY 1.9298 344 INSTILLATION OF RADIOELEMENT SOLUTIONS 2.4223 345 HYPERTHERMIC THERAPIES 0.9459 346 RADIOSURGERY 63.9723 347 HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY 0.7966 348 PROTON TREATMENT DELIVERY 4.5955 350 LEVEL I ADJUNCTIVE GENERAL DENTAL SERVICES 0.4639 351 LEVEL II ADJUNCTIVE GENERAL DENTAL SERVICES 1.3073 352 PERIODONTICS 0.8133 353 LEVEL I PROSTHODONTICS, FIXED 0.4550 354 LEVEL II PROSTHODONTICS, FIXED 1.7021 355 LEVEL III PROSTHODONTICS, FIXED 2.1055 356 LEVEL I PROSTHODONTICS, REMOVABLE 0.9221 357 LEVEL II PROSTHODONTICS, REMOVABLE 1.7644 358 LEVEL III PROSTHODONTICS, REMOVABLE 1.3580 359 LEVEL I MAXILLOFACIAL PROSTHETICS 0.2562 360 LEVEL II MAXILLOFACIAL PROSTHETICS 1.3379 361 LEVEL I DENTAL RESTORATIONS 0.6561 362 LEVEL II DENTAL RESTORATIONS 0.9844 363 LEVEL III DENTAL RESTORATION 2.3474 364 LEVEL I ENDODONTICS 0.6251 365 LEVEL II ENDODONTICS 1.1241 366 LEVEL III ENDODONTICS 1.1324 367 LEVEL I ORAL AND MAXILLOFACIAL SURGERY 0.7491 368 LEVEL II ORAL AND MAXILLOFACIAL SURGERY 2.0751 369 LEVEL III ORAL AND MAXILLOFACIAL SURGERY 2.0751 370 LEVEL IV ORAL AND MAXILLOFACIAL SURGERY 2.0751 371 ORTHODONTICS 0.0000 372 SEALANT 0.2676 373 LEVEL I DENTAL FILM 0.1338 374 LEVEL II DENTAL FILM 0.4631 375 DENTAL ANESTHESIA 1.7348 376 DIAGNOSTIC DENTAL PROCEDURES 0.2264 377 PREVENTIVE DENTAL PROCEDURES 0.3168 380 ANESTHESIA 1.3350 390 LEVEL I PATHOLOGY 0.3956 391 LEVEL II PATHOLOGY 0.8844 392 PAP SMEARS 0.1782 393 BLOOD AND TISSUE TYPING 0.3199 394 LEVEL I IMMUNOLOGY TESTS 0.1492 395 LEVEL II IMMUNOLOGY TESTS 0.1626 396 LEVEL I MICROBIOLOGY TESTS 0.1137 397 LEVEL II MICROBIOLOGY TESTS 0.2141 398 LEVEL I ENDOCRINOLOGY TESTS 0.1526 399 LEVEL II ENDOCRINOLOGY TESTS 0.2258 400 LEVEL I CHEMISTRY TESTS 0.1150 401 LEVEL II CHEMISTRY TESTS 0.2952 402 BASIC CHEMISTRY TESTS 0.0857 403 ORGAN OR DISEASE ORIENTED PANELS 0.1367 404 TOXICOLOGY TESTS 0.3084 405 THERAPEUTIC DRUG MONITORING 0.1463 406 LEVEL I CLOTTING TESTS 0.0593 407 LEVEL II CLOTTING TESTS 0.2111 408 LEVEL I HEMATOLOGY TESTS 0.0831 409 LEVEL II HEMATOLOGY TESTS 0.1427 410 URINALYSIS 0.0669 411 BLOOD AND URINE DIPSTICK TESTS 0.0535 412 SIMPLE PULMONARY FUNCTION TESTS 0.4482 413 CARDIOGRAM 0.2274 414 LEVEL I IMMUNIZATION AND ALLERGY IMMUNOTHERAPY 0.2475 415 LEVEL II IMMUNIZATION 0.3478 416 LEVEL III IMMUNIZATION 0.8428 417 MINOR REPRODUCTIVE PROCEDURES 0.8869 418 MINOR CARDIAC AND VASCULAR TESTS 1.0853 419 MINOR OPHTHALMOLOGICAL INJECTION, SCRAPING AND TESTS 0.5399 420 PACEMAKER AND OTHER ELECTRONIC ANALYSIS 0.3735 421 TUBE CHANGE 2.4389 422 PROVISION OF VISION AIDS 0.4387 423 INTRODUCTION OF NEEDLE AND CATHETER 2.1414 424 DRESSINGS AND OTHER MINOR PROCEDURES 0.6994 425 OTHER MISCELLANEOUS ANCILLARY PROCEDURES 0.4347 426 PSYCHOTROPIC MEDICATION MANAGEMENT 0.3448 427 BIOFEEDBACK AND OTHER TRAINING 0.0000 426 PATIENT EDUCATION, INDIVIDUAL 0.0000 427 PATIENT EDUCATION, GROUP 0.0000 428 CLASS I CHEMOTHERAPY DRUGS 0.0000 429 CLASS II CHEMOTHERAPY DRUGS 0.0000 430 CLASS III CHEMOTHERAPY DRUGS 0.0000 431 CLASS IV CHEMOTHERAPY DRUGS 0.0000 432 CLASS V CHEMOTHERAPY DRUGS 0.0000 433 CLASS I PHARMACOTHERAPY 0.1061 436 CLASS II PHARMACOTHERAPY 1.2529 437 CLASS III PHARMACOTHERAPY 2.7208 438 CLASS IV PHARMACOTHERAPY 4.7852 439 CLASS V PHARMACOTHERAPY 12.2876 440 CLASS VI PHARMACOTHERAPY 20.0367 441 CLASS VI CHEMOTHERAPY DRUGS 0.0000 442 CLASS VII COMBINED CHEMOTHERAPY & PHARMACOTHERAPY 0.0000 448 EXPANDED HOURS ACCESS 0.0759 449 Additional undifferentiated medical visit/services 0.0000 450 OBSERVATION 0.0000 451 SMOKING CESSATION TREATMENT 0.1100 452 DIABETES SUPPLIES 0.0000 453 MOTORIZED WHEELCHAIR 0.0000 454 TPN FORMULAE 0.0000 455 IMPLANTED TISSUE OF ANY TYPE 7.2736 456 MOTORIZED WHEELCHAIR ACCESSORIES 0.0000 457 VENIPUNCTURE 0.0602 470 OBSTETRICAL ULTRASOUND 0.9405 471 PLAIN FILM 0.4758 472 ULTRASOUND GUIDANCE 1.2632 473 CT GUIDANCE 1.2002 474 RADIOLOGICAL GUIDANCE FOR THERAPEUTIC OR DIAGNOSTIC PROCEDURES 2.3045 475 MRI GUIDANCE 2.3306 476 LEVEL I THERAPEUTIC RADIATION TREATMENT PREPARATION 2.3082 477 LEVEL II THERAPEUTIC RADIATION TREATMENT PREPARATION 2.3097 478 MEDICAL RADIATION PHYSICS 0.7463 479 TREATMENT DEVICE DESIGN AND CONSTRUCTION 1.7071 480 TELETHERAPY/BRACHYTHERAPY CALCULATION 1.7080 481 THERAPEUTIC RADIOLOGY SIMULATION FIELD SETTING 4.1129 482 RADIOELEMENT APPLICATION 3.1301 483 RADIATION THERAPY MANAGEMENT 2.5251 484 THERAPEUTIC RADIOLOGY TREATMENT PLANNING 1.7963 490 INCIDENTAL TO MEDICAL, SIGNIFICANT PROCEDURE OR THERAPY VISIT 0.0000 491 MEDICAL VISIT INDICATOR 0.7995 492 ADMISSION FOR OBSERVATION INDICATOR 0.0000 500 DIRECT ADMISSION FOR OBSERVATION – OBSTETRICAL 0.0000 501 DIRECT ADMISSION FOR OBSERVATION – OTHER DIAGNOSES 0.0000 510 MAJOR SIGNS, SYMPTOMS AND FINDINGS 0.8466 520 SPINAL DISORDERS & INJURIES 0.8689 521 NERVOUS SYSTEM MALIGNANCY 0.7216 522 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 0.8448 523 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES 0.7490 524 LEVEL I CNS DISORDERS 0.9420 525 LEVEL II CNS DISORDERS 0.8167 526 TRANSIENT ISCHEMIA 0.8838 527 PERIPHERAL NERVE DISORDERS 0.7377 528 NONTRAUMATIC STUPOR & COMA 0.8956 529 SEIZURE 0.9218 530 HEADACHES OTHER THAN MIGRAINE 0.8208 531 MIGRAINE 0.7556 532 HEAD TRAUMA 0.7274 533 AFTEREFFECTS OF CEREBROVASCULAR ACCIDENT 0.8360 534 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARC 0.9246 535 CVA & PRECEREBRAL OCCLUSION W INFARCT 0.8058 550 ACUTE MAJOR EYE INFECTIONS 0.6374 551 CATARACTS 0.8106 552 GLAUCOMA 0.7766 553 LEVEL I OPHTHALMIC DIAGNOSES 0.7034 554 LEVEL II OPHTHALMIC DIAGNOSES 0.7757 555 CONJUNCTIVITIS 0.6301 560 EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES 0.8000 561 VERTIGINOUS DISORDERS EXCEPT FOR BENIGN VERTIGO 0.8235 562 INFECTIONS OF UPPER RESPIRATORY TRACT 0.6284 563 DENTAL & ORAL DISEASES & INJURIES 0.5307 564 LEVEL I OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 0.7677 565 LEVEL II OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 0.8622 570 CYSTIC FIBROSIS – PULMONARY DISEASE 0.7880 571 RESPIRATORY MALIGNANCY 0.7905 572 BRONCHIOLITIS & RSV PNEUMONIA 0.5136 573 COMMUNITY ACQUIRED PNUEMONIA 0.6791 574 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 0.6893 575 ASTHMA 0.7979 576 LEVEL I OTHER RESPIRATORY DIAGNOSES 0.7013 577 LEVEL II OTHER RESPIRATORY DIAGNOSES 0.8384 578 PNEUMONIA EXCEPT FOR COMMUNITY ACQUIRED PNEUMONIA 0.6586 579 STATUS ASTHMATICUS 0.9027 591 ACUTE MYOCARDIAL INFARCTION 2.2552 592 LEVEL I CARDIOVASCULAR DIAGNOSES 0.7853 593 LEVEL II CARDIOVASCULAR DIAGNOSES 0.8735 594 HEART FAILURE 0.8490 595 CARDIAC ARREST 1.1669 596 PERIPHERAL & OTHER VASCULAR DISORDERS 0.8313 597 PHLEBITIS 0.5608 598 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 0.7776 599 HYPERTENSION 0.7924 600 CARDIAC STRUCTURAL & VALVULAR DISORDERS 0.8305 601 LEVEL I CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 0.8097 602 ATRIAL FIBRILLATION 0.8178 603 LEVEL II CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 1.0425 604 CHEST PAIN 0.8151 605 SYNCOPE & COLLAPSE 0.7943 620 DIGESTIVE MALIGNANCY 0.7214 621 PEPTIC ULCER & GASTRITI 1.0541 623 ESOPHAGITIS 0.7081 624 LEVEL I GASTROINTESTINAL DIAGNOSES 0.7720 625 LEVEL II GASTROINTESTINAL DIAGNOSES 0.7720 626 INFLAMMATORY BOWEL DISEASE 0.8255 627 NON–BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING 0.7240 628 ABDOMINAL PAIN 0.8099 629 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE 1.0179 630 CONSTIPATION 0.7712 631 HERNIA 0.8163 632 IRRITABLE BOWEL SYNDROME 0.6753 633 ALCOHOLIC LIVER DISEASE 0.8245 634 MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS 0.8924 635 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 0.7530 636 HEPATITIS WITHOUT COMA 0.8736 637 DISORDERS OF GALLBLADDER & BILIARY TRACT 0.7058 638 CHOLECYSTITIS 0.7463 639 LEVEL I HEPATOBILIARY DIAGNOSES 0.8765 640 LEVEL II HEPATOBILIARY DIAGNOSES 0.7030 650 FRACTURE OF FEMUR0 7209 651 FRACTURE OF PELVIS OR DISLOCATION OF HIP 0.6540 652 FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK 0.7464 653 MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG 0.5615 654 OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS 0.7358 655 CONNECTIVE TISSUE DISORDERS 0.7816 656 BACK & NECK DISORDERS EXCEPT LUMBAR DISC DISEASE 0.7486 657 LUMBAR DISC DISEASE 0.7188 658 LUMBAR DISC DISEASE WITH SCIATICA 0.7287 659 MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE 0.6927 660 LEVEL I OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES 0.6864 661 LEVEL II OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES 0.7158 662 OSTEOPOROSIS 0.7418 663 PAIN 0.6247 670 SKIN ULCERS 0.7083 671 MAJOR SKIN DISORDERS 0.7542 672 MALIGNANT BREAST DISORDERS 0.7032 673 CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS 0.7130 674 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE 0.7721 675 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS 0.7569 676 DECUBITUS ULCER 0.8081 690 MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS 0.7912 691 INBORN ERRORS OF METABOLISM 0.7457 692 LEVEL I ENDOCRINE DISORDERS 0.7671 693 LEVEL II ENDOCRINE DISORDERS 0.7757 694 ELECTROLYTE DISORDERS 0.7607 695 OBESITY 0.6351 710 DIABETES WITH OPHTHALMIC MANIFESTATIONS 0.7645 711 DIABETES WITH CIRCULATORY DIAGNOSES 0.8886 712 DIABETES WITH NEUROLOGIC MANIFESTATIONS 0.8010 713 DIABETES WITHOUT COMPLICATIONS 0.7405 714 DIABETES WITH RENAL MANIFESTATIONS 0.7779 720 RENAL FAILURE 0.7758 721 KIDNEY & URINARY TRACT MALIGNANCY 0.7536 722 NEPHRITIS & NEPHROSIS 1.0495 723 KIDNEY AND CHRONIC URINARY TRACT INFECTIONS 0.6344 724 URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION 0.8226 725 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC 0.9526 726 OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS 0.8033 727 ACUTE LOWER URINARY TRACT INFECTIONS 0.8930 740 MALIGNANCY, MALE REPRODUCTIVE SYSTEM 0.7722 741 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 0.8213 742 NEOPLASMS OF THE MALE REPRODUCTIVE SYSTEM 0.7359 743 PROSTATITIS 0.8646 744 MALE REPRODUCTIVE INFECTIONS 0.8231 750 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 0.7049 751 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 0.8056 752 LEVEL I MENSTRUAL AND OTHER FEMALE DIAGNOSES 0.7361 753 LEVEL II MENSTRUAL AND OTHER FEMALE DIAGNOSES 0.8135 760 VAGINAL DELIVER 0.7511 761 POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE 0.8639 762 THREATENED ABORTION 0.9263 763 ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.9720 764 FALSE LABOR 1.1301 765 OTHER ANTEPARTUM DIAGNOSES 0.8176 766 ROUTINE PRENATAL CARE 0.7961 770 NORMAL NEONATE 0.4722 771 LEVEL I NEONATAL DIAGNOSES 1.3476 772 LEVEL II NEONATAL DIAGNOSES 0.9587 780 OTHER HEMATOLOGICAL DISORDERS 0.9255 781 COAGULATION & PLATELET DISORDERS 0.7856 782 CONGENITAL FACTOR DEFICIENCIES 0.9455 783 SICKLE CELL ANEMIA CRISIS 0.9420 784 SICKLE CELL ANEMIA 0.8978 785 ANEMIA EXCEPT FOR IRON DEFICIENCY ANEMIA AND SICKLE CELL ANEMIA 0.7984 786 IRON DEFICIENCY ANEMIA 0.7968 800 ACUTE LEUKEMIA 0.7835 801 LYMPHOMA, MYELOMA & NON–ACUTE LEUKEMIA 0.8165 802 RADIOTHERAPY 0.6563 803 CHEMOTHERAPY 2.0576 804 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR 0.8889 805 SEPTICEMIA & DISSEMINATED INFECTIONS 0.8668 806 POST–OPERATIVE, POST–TRAUMATIC, OTHER DEVICE INFECTIONS 0.7795 807 FEVER 0.4439 808 VIRAL ILLNESS 0.8734 809 OTHER INFECTIOUS & PARASITIC DISEASES 0.7634 810 H. PYLORI INFECTION 0.7593 820 SCHIZOPHRENIA 0.8969 821 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 0.9476 822 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.8945 823 BIPOLAR DISORDERS 0.8574 824 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 0.6982 825 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 0.8061 826 ACUTE ANXIETY & DELIRIUM STATES 0.6352 827 ORGANIC MENTAL HEALTH DISTURBANCES 0.7817 828 MENTAL RETARDATION 0.7149 829 CHILDHOOD BEHAVIORAL DISORDERS 0.5939 830 EATING DISORDERS 0.9135 831 OTHER MENTAL HEALTH DISORDERS 0.7248 840 OPIOID ABUSE & DEPENDENCE 0.7268 841 COCAINE ABUSE & DEPENDENCE 0.7268 842 ALCOHOL ABUSE & DEPENDENCE 1.0469 843 OTHER DRUG ABUSE & DEPENDENCE 0.9946 850 ALLERGIC REACTIONS 0.9126 851 POISONING OF MEDICINAL AGENTS 0.9544 852 OTHER COMPLICATIONS OF TREATMENT 0.9691 853 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES 0.9800 854 TOXIC EFFECTS OF NON–MEDICINAL SUBSTANCES 0.7857 860 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT 0.5979 861 PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT 0.7094 870 REHABILITATION 0.4136 871 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS 0.7656 872 OTHER AFTERCARE & CONVALESCENCE 0.8477 873 NEONATAL AFTERCARE 0.8308 874 JOINT REPLACEMENT 0.8105 880 HIV INFECTION 1.1427 881 AIDS 1.0495 993 INPATIENT ONLY PROCEDURES 0.0000 994 USER CUSTOMIZABLE INPATIENT PROCEDURES 0.0000 999 UNASSIGNED 0.0000 - The procedures that will be paid using procedure–specific weights and their associated weights are:
January 2010 Procedure–Based Weights
Px–Based Units
HCPCS | HCPCS Description | Weight | Limit |
---|---|---|---|
90805 | Psytx, off, 20–30 min w/e&m | 1.0344 | 1 |
90807 | Psytx, off, 45–50 min w/e&m | 1.2413 | 1 |
90809 | Psytx, off, 75–80, w/e&m | 1.2413 | 1 |
90811 | Intact psytx, 20–30, w/e&m | 1.0344 | 1 |
90813 | Intact psytx, 45–50 min w/e&m | 1.2413 | 1 |
90815 | Intact psytx, 75–80 w/e&m | 1.2413 | 1 |
90819 | Psytx, hosp, 45–50 min w/e&m | 1.2413 | 1 |
90847 | Family psytx w/patient | 1.2413 | 1 |
90862 | Medication management | 0.8275 | 1 |
90882 | Environmental manipulation | 0.2896 | 1 |
92065 | Orthoptic/pleoptic training | 0.3820 | 1 |
92340 | Fitting of spectacles | 0.2624 | 1 |
92341 | Fitting of spectacles | 0.2624 | 1 |
92342 | Fitting of spectacles | 0.2624 | 1 |
92607 | Ex for speech device rx, 1hr | 0.8827 | 1 |
92608 | Ex for speech device rx addl | 0.8827 | 1 |
96101 | Psycho testing by psych/phys | 1.6551 | 1 |
96102 | Psycho testing by technician | 1.2413 | 1 |
96111 | Developmental test, extend | 1.2413 | 1 |
96116 | Neurobehavioral status exam | 6551 | 1 |
96118 | Neuropsych tst by psych/phys | 1.6551 | 1 |
96119 | Neuropsych testing by tec | 2413 | 1 |
96125 | Cognitive test by hc pro | 1.2413 | 1 |
96150 | Assess hlth/behave, init | 0.1517 | 3 |
96151 | Assess hlth/behave, subseq | 0.1448 | 3 |
96152 | Intervene hlth/behave, indiv | 0.1379 | 3 |
96153 | Intervene hlth/behave, group | 0.0690 | 4 |
96154 | Interv hlth/behav, fam w/pt | 0.1379 | 4 |
96155 | Interv hlth/behav, fam w/o pt | 0.1517 | 4 |
97032 | Electrical stimulation, 15 min | 0.2276 | 3 |
97033 | Electric current therapy, 15 min | 0.2276 | 3 |
97034 | Contrast bath therapy, 15 min | 0.2276 | 3 |
97035 | Ultrasound therapy, 15 min | 0.2276 | 3 |
97036 | Hydrotherapy, 15 min | 0.2276 | 3 |
97110 | Therapeutic exercises, 15 min | 0.2276 | 3 |
97112 | Neuromuscular reeducation | 0.2276 | 3 |
97113 | Aquatic therapy/exercises | 0.2276 | 3 |
97116 | Gait training therapy | 0.2276 | 3 |
97124 | Massage therapy, 15 min | 0.2276 | 3 |
97140 | Manual therapy, 15 min | 0.2276 | 3 |
97530 | Therapeutic activities, 15 min | 0.2276 | 3 |
97532 | Cognitive skills development, 15 min | 0.2414 | 3 |
97533 | Sensory integration, 15 min | 0.2414 | 3 |
97535 | Self care mngment training, 15 min | 0.2414 | 3 |
97537 | Community/work reintegration, 15 min | 0.2414 | 3 |
97542 | Wheelchair mngment training, 15 min | 0.2414 | 3 |
97750 | Physical performance test, 15 min | 0.2276 | 3 |
97755 | Assistive technology assess, 15 min | 0.2276 | 3 |
97760 | Orthotic mgmt and training, 15 min | 0.2276 | 3 |
97761 | Prosthetic training, 15 min | 0.2276 | 3 |
97762 | C/o for orthotic/prosth use, 15 min | 0.2276 | 3 |
97802 | Medical nutrition, indiv, each 15 min | 0.1793 | 2 |
97803 | Med nutrition, indiv, subseq, each 15 min | 0.1793 | 2 |
97804 | Medical nutrition, group, each 30 min | 0.3448 | 1 |
97810 | Acupunct w/o stimul 15 min | 0.2276 | 3 |
98960 | Self–mgmt educ & train, 1 pt, 30 min | 0.1379 | 4 |
98961 | Self–mgmt educ/train, 2–4 pt | 0.0690 | 4 |
98962 | Self–mgmt educ/train, 5–8 pt | 0.0690 | 4 |
99002 | DEVICE HANDLING | 0.7586 | 1 |
99401 | Preventive counseling, indiv | 0.1724 | 1 |
99402 | Preventive counseling, indiv | 0.3103 | 1 |
99403 | Preventive counseling, indiv | 0.4482 | 1 |
99404 | Preventive counseling, indiv | 0.5862 | 1 |
99411 | Preventive counseling, group | 0.1379 | 1 |
99412 | Preventive counseling, group | 0.2414 | 1 |
G0108 | Diab manage trn per indiv | 0.1379 | 4 |
G0109 | Diab manage trn ind/group | 0.0690 | 4 |
G0270 | MNT subs tx for change dx, each 15 min | 0.1793 | 2 |
G0271 | Group MNT 2 or more 30 mins | 0.1517 | 1 |
H0001 | Alcohol and/or drug assessment | 0.8965 | 1 |
H0006 | Alcohol and/or drug services | 0.4138 | 1 |
H0023 | Behavioral health outreach service | 0.7034 | 1 |
H0031 | MH health assess by non–md | 0.8965 | 1 |
H0038 | Self–help/peer services per 15 min | 0.0000 | 1 |
H1000 | Prenatal care atrisk assessm | 0.2069 | 1 |
H1005 | Prenatal care enhanced srv pk | 0.0690 | 1 |
H2010 | Comprehensive med svc 15 min | 0.4138 | 1 |
H2011 | Crisis interven svc, per 15 min | 0.2069 | 8 |
S9484 | Crisis intervention per hour | 2.4136 | 1 |
S9485 | Crisis intervention mental h | 5.7927 | 1 |
T1007 | Treatment Plan Development | 0.4138 | 1 |
V2020 | Vision svcs frames purchases | 0.3567 | 1 |
V2103 | Spherocylindr 4.00d/12–2.00d | 0.3567 | 1 |
V2200 | Lens spher bifoc plano 4.00d | 0.3567 | 1 |
V2203 | Lens sphcyl bifocal 4.00d/.1 | 0.3567 | 1 |
V5010 | Assessment for hearing aid | 0.1724 | 1 |
V5020 | Conformity evaluation | 0.0690 | 1 |
V5160 | Dispensing fee binaural | 1.3792 | 1 |
V5200 | Cros hearing aid dispens fee | 1.3792 | 1 |
V5240 | Dispensing fee bicros | 1.3792 | 1 |
V5241 | Dispensing fee, monaural | 0.9310 | 1 |
Subdivision (d) of section 86–8.9 is amended, and a new subdivision (e) of section 86–8.9 is added, to read as follows:
(d) In cases where the only reimbursable APGs for a visit are one or more of the following [ancillary service] APGs, there shall be no reimbursement for capital costs included in the payment for that visit
94 CARDIAC REHABILITATION
PHYSICAL THERAPY, GROUP
SPEECH THERAPY AND EVALUATION, GROUP
322 MEDICATION ADMINISTRATION AND OBSERVATION
414 LEVEL I IMMUNIZATION AND ALLERGY IMMUNOTHERAPY
415 LEVEL II IMMUNIZATION
416 LEVEL III IMMUNIZATION
428 PATIENT EDUCATION, INDIVIDUAL
429 PATIENT EDUCATION, GROUP
(e) The following APGs shall be designated as "no blend APGs" and shall have their payments calculated solely under the APG reimbursement methodology.
94 Cardiac Rehabilitation
310 Developmental and Neuropsychological Testing
312 Full Day Partial Hospitalization for Mental Illness
321 Crisis Intervention
322 Medication Administration and Observation
414 Level I Immunization and Allergy Immunotherapy
415 Level II Immunization
416 Level III Immunization
426 Medication Management
428 Patient Education, Individual
429 Patient Education, Group
448 After Hours Services
451 Smoking Cessation Treatment
Subdivisions (h) and (i) of section 86–8.10 are amended to read as follows:
(h) The following APGs shall not be eligible for reimbursement pursuant to this Subpart:
065 RESPIRATORY THERAPY
066 PULMONARY 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 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
441 CLASS VI CHEMOTHERAPY DRUGS
442 CLASS VII COMBINED CHEMOTHERPAY & PHARMACOTHERAPY
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
(i) The following APGs shall not be eligible for reimbursement pursuant to this Subpart when they are presented as the only APGs applicable to a patient visit or when the only other APGs presented with them are one or more of the APGs listed in subdivision (h) of this section:
118 NUTRITION THERAPY
280 VASCULAR RADIOLOGY EXCEPT VENOGRAPHY OF EXTREMITY
281 MAGNETIC RESONANCE ANGIOGRAPHY – HEAD AND/OR NECK
282 MAGNETIC RESONANCE ANGIOGRAPHY – CHEST
283 MAGNETIC RESONANCE ANGIOGRAPHY – OTHER SITES
284 MYELOGRAPHY
285 MISCELLANEOUS RADIOLOGICAL PROCEDURES WITH CONTRAST
286 MAMMOGRAPHY
287 DIGESTIVE RADIOLOGY
288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR OF LOWER EXTREMITIES
289 VASCULAR DIAGNOSTIC ULTRASOUND OF LOWER EXTREMITIES
290 PET SCANS
291 BONE DENSITOMETRY
292 MRI – ABDOMEN
293 MRI – JOINTS
294 MRI – BACK
295 MRI – CHEST
296 MRI – OTHER
297 MRI – BRAIN
298 CAT SCAN BACK
299 CAT SCAN – BRAIN
300 CAT SCAN – ABDOMEN
301 CAT SCAN – OTHER
302 ANGIOGRAPHY, OTHER
303 ANGIOGRAPHY, CEREBRAL
330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE
331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE
332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE
373 LEVEL I DENTAL FILM
LEVEL II DENTAL FILM
DENTAL ANESTHESIA
380 ANESTHESIA
390 LEVEL I PATHOLOGY
391 LEVEL II PATHOLOGY
392 PAP SMEARS
393 BLOOD AND TISSUE TYPING
394 LEVEL I IMMUNOLOGY TESTS
395 LEVEL II IMMUNOLOGY TESTS
396 LEVEL I MICROBIOLOGY TESTS
397 LEVEL II MICROBIOLOGY TESTS
398 LEVEL I ENDOCRINOLOGY TESTS
399 LEVEL II ENDOCRINOLOGY TESTS
400 LEVEL I CHEMISTRY TESTS
401 LEVEL II CHEMISTRY TESTS
402 BASIC CHEMISTRY TESTS
403 ORGAN OR DISEASE ORIENTED PANELS
404 TOXICOLOGY TESTS
405 THERAPEUTIC DRUG MONITORING
406 LEVEL I CLOTTING TESTS
407 LEVEL II CLOTTING TESTS
408 LEVEL I HEMATOLOGY TESTS
409 LEVEL II HEMATOLOGY TESTS
410 URINALYSIS
411 BLOOD AND URINE DIPSTICK TESTS
413 CARDIOGRAM
414 LEVEL I IMMUNIZATION AND ALLERGY IMMUNOTHERAPY
415 LEVEL II IMMUNIZATION
416 LEVEL III IMMUNIZATION
435 CLASS I PHARMACOTHERAPY
436 CLASS II PHARMACOTHERAPY
437 CLASS III PHARMACOTHERAPY
438 CLASS IV PHARMACOTHERAPY
439 CLASS V PHARMACOTHERAPY
440 CLASS VI PHARMACOTHERAPY
451 SMOKING CESSATION TREATMENT
455 IMPLANTED TISSUE OF ANY TYPE
457 VENIPUNCTURE
470 OBSTETRICAL ULTRASOUND
471 PLAIN FILM
472 ULTRASOUND GUIDANCE
473 CT GUIDANCE
REGULATORY IMPACT STATEMENT
Statutory Authority:
Authority for the promulgation of these regulations is contained in section 2807(2–a)(e) of the Public Health Law, section 79(u) of part C of chapter 58 of the laws of 2008 and section 129(l) of part C of chapter 58 of the laws of 2009, which authorizes the Commissioner of Health to adopt and amend rules and regulations, subject to the approval of the State Director of the Budget, establishing an Ambulatory Patient Groups methodology for determining Medicaid rates of payment for diagnostic and treatment center services, free–standing ambulatory surgery services and general hospital outpatient clinics, emergency departments and ambulatory surgery services.
Legislative Objective:
The Legislature´s mandate is to convert, where appropriate, Medicaid reimbursement of ambulatory care services to a system that pays differential amounts based on the resources required for each patient visit, as determined through APGs.
Needs and Benefits:
The proposed regulations are in conformance with statutory amendments to provisions of Public Health Law section 2807(2–a), which mandated implementation of a new ambulatory care reimbursement methodology based on APGs This reimbursement methodology provides greater reimbursement for high intensity services and relatively less reimbursement for low intensity services It also allows for greater payment homogeneity for comparable services across all ambulatory care settings (i.e., Outpatient Department, Ambulatory Surgery, Emergency Department, and Diagnostic and Treatment Centers) By linking payments to the specific array of services rendered, APGs will make Medicaid reimbursement more transparent APGs provide strong fiscal incentives for health care providers to improve the quality of, and access to, preventive and primary care services.
COSTS
Costs for the Implementation of, and Continuing Compliance with this Regulation to the Regulated Entity:
There will be no additional costs to providers as a result of these amendments.
Costs to Local Governments:
There will be no additional costs to local governments as a result of these amendments.
Costs to State Governments:
There will be no additional costs to NYS as a result of these amendments All expenditures under this regulation are fully budgeted in the SFY 09/10 enacted budget Costs to the Department of Health:
There will be no additional costs to the Department of Health as a result of these amendments.
Paperwork:
There is no additional paperwork required of providers as a result of these amendments.
Duplication:
This regulation does not duplicate other state or federal regulations.
Alternatives:
These regulations are in conformance with Public Health Law section 2807(2–a). Alternatives would require statutory amendments.
Federal Standards:
This amendment does not exceed any minimum standards of the federal government for the same or similar subject areas.
Compliance Schedule:
The proposed amendment will become effective upon filing with the Department of State.
Contact Person:
Ms Katherine CeroaloNew 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.state.ny.us
REGULATORY FLEXIBILITY ANALYSIS FOR SMALL BUSINESS AND LOCAL GOVERNMENTS
Effect on Small Business and Local Governments:
For the purpose of this regulatory flexibility analysis, small businesses were considered to be general hospitals, diagnostic and treatment centers, and free–standing ambulatory surgery centers Based on recent data extracted from providers´ submitted cost reports, seven hospitals and 245 DTCs were identified as employing fewer than 100 employees.
Compliance Requirements:
No new reporting, record keeping or other compliance requirements are being imposed as a result of these rules.
Professional Services:
No new or additional professional services are required in order to comply with the proposed amendments.
Economic and Technical Feasibility:
Small businesses will be able to comply with the economic and technological aspects of this rule The proposed amendments are intended to further reform the outpatient/ambulatory care fee–for–service Medicaid payment system, which is intended to benefit health care providers, including those with fewer than 100 employees.
Compliance Costs:
No initial capital costs will be imposed as a result of this rule, nor is there an annual cost of compliance.
Minimizing Adverse Impact:
The proposed amendments apply to certain services of general hospitals, diagnostic and treatment centers and freestanding ambulatory surgery centers The Department of Health considered approaches specified in section 202–b (1) of the State Administrative Procedure Act in drafting the proposed amendments and rejected them as inappropriate given that this reimbursement system is mandated in statute.
Small Business and Local Government Participation:
Local governments and small businesses were given notice of these proposals by their inclusion in the SFY 2009–10 enacted budget and the Department´s issuance in the State Register of federal public notices on February 25, 2009, and June 10, 2009.
RURAL AREA FLEXIBILITY ANALYSIS
Effect on Rural Areas:
Rural areas are defined as counties with a population less than 200,000 and, for counties with a population greater than 200,000, includes towns with population densities of 150 persons or less per square mile The following 44 counties have a population less than 200,000:
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 | Lawrence | Yates |
Greene | Saratoga |
The following 9 counties have certain townships with population densities of 150 persons or less per square mile:
Albany | Erie | Oneida |
Broome | Monroe | Onondaga |
Dutchess | Niagara | Orange |
Compliance Requirements:
No new reporting, record keeping, or other compliance requirements are being imposed as a result of this proposal.
Professional Services:
No new additional professional services are required in order for providers in rural areas to comply with the proposed amendments.
Compliance Costs:
No initial capital costs will be imposed as a result of this rule, nor is there an annual cost of compliance.
Minimizing Adverse Impact:
The proposed amendments apply to certain services of general hospitals, diagnostic and treatment centers and freestanding ambulatory surgery centers The Department of Health considered approaches specified in section 202–bb (2) of the State Administrative Procedure Act in drafting the proposed amendments and rejected them as inappropriate given that the reimbursement system is mandated in statute.
Opportunity for Rural Area Participation:
Rural areas were given notice of these proposals by their inclusion in the SFY 2009–10 enacted budget and the Department´s issuance in the State Register of federal public notices on February 25, 2009 and June, 10, 2009.
JOB IMPACT STATEMENT
A Job Impact Statement is not required pursuant to Section 201–a(2)(a) of the State Administrative Procedure Act It is apparent, from the nature and purpose of the proposed regulations, that they will not have a substantial adverse impact on jobs or employment opportunities.
EMERGENCY JUSTIFICATION
It is necessary to issue the proposed regulation on an emergency basis in order to meet the regulatory requirement found within the regulation itself to update the Ambulatory Patient Group (APG) weights at least once a year To meet that requirement, the weights needed to be revised and published in the regulation for January 2010 Additionally, the regulation needs to reflect the many software changes made to the APG payment software, known as the APG grouper–pricer, which is a sub–component of the eMedNY Medicaid payment system These changes include revised lists of payable and non–payable APGs, a new list of APGs that are not eligible for a capital add–on, and a list of APGs that are not subject to having their payment "blended" with provider–specific historical payment amounts Finally, a brand new payment software enhancement, which allows payment on a procedure code–specific basis rather than an APG basis, needs to be reflected in the regulation.
There is a compelling interest in enacting these amendments immediately in order to secure federal approval of associated Medicaid State Plan amendments and assure there are no delays in implementation of these provisions APGs represent the cornerstone to health care reform Their continued refinement is necessary to assure access to preventive services for all Medicaid recipients.