NY Changes in Ambulatory Patient Group (APG) Reimbursement

Changes in APG Reimbursement

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Effective January 1, 2010

Overview of APG Payment Changes for January 1, 2010

  1. Visit–based rate codes will be eliminated (except for ambulatory surgery services).
  2. Updated APG weights and revised base rates
  3. New enhanced hospital MR/DD/TBI base rate paying a 20% bump for patients with RE code 95 or RE code 81.
  4. Pharmacotherapy and chemotherapy classifications will expand from 5 to 6 levels (however, chemo drugs will continue to be carved out).
  5. A new "premium" drug APG was created comprising both pharmacotherapy and chemotherapy drugs.  This APG, and its associated drugs, will be carved out of APGs and will be billable as ordered ambulatory.
  6. APGs will recognize units of service for some PT, OT, and nutrition procedure codes, as well as crisis management, patient education (including services rendered by CDEs & CAEs), and health/behavioral assessments.
  7. Medical visits will not package with significant ancillaries (e.g., MRIs), dental procedures, PT, OT, speech, and counseling services and will instead pay at the line level. All significant ancillaries will become "if stand alone, do not pay" procedures.
  8. Multiple same APG discounting (rather than consolidation) which currently applies to most dental services will be expanded to include dental sealants, OT, PT, speech, and most mental hygiene APGs.
  9. Genetic testing procedures will be carved out and paid using the ordered ambulatory services fee schedule.
  10. The no–blend APG list will be expanded to include cardiac rehabilitation (which comes off the never pay APG list in January), developmental testing, crisis management, medication administration, and medication management.
  11. The following new APGs were created:
    • Physical Therapy – Group
    • Speech Therapy – Group
    • Crisis Intervention
    • Medication Administration and Observation (primarily developed for MMTP, which will not move to APGs in January 2010)
    • Mental Hygiene Assessment
    • Mental Hygiene Screening and Brief Assessment
  12. Some procedures (e.g., provision of vision aids) will be paid based on procedure–specific weights rather than APG–specific weights.
  13. Capital add–on rules will change so that an add–on is paid for nearly all types of visits including those consisting entirely of ancillaries and dental examinations (currently, a capital add–on is not paid with ancillary only visits).
    • However, a capital add–on will not be paid for visits consisting solely of medication administration, PT–group, speech–group, cardiac rehabilitation, immunization, and patient education.

Additional Major Program & Policy Changes

  1. Statewide Patient–Centered Medical Home Incentive Program (implementation on Federal approval).
  2. Physician Carve Out policy effective for OPDs (scheduled for February 1, 2010 implementation).

New Episode–Based Payment Will Replace Visit–Based Payment

  • Beginning January 1, 2010 OPDs and SBHCs must use new episode–based rate codes (1432 and 1450) for Medicaid patients. Providers may continue to use visit based rate codes for dual eligible recipients.
  • Under episode pricing, the APG Grouper Pricer will view all procedures coded on a claim as being part of the same visit, regardless of the coded dates of service.
    • Providers will no longer have to "reassign" the actual date of service for related ancillaries to the same date of service as the initial medical visit or procedure.
  • An episode is defined as all medical visits and/or significant procedures that occur on a single date of service, as well as any associated ancillaries that occurred on or after the date of the medical visit and/or significant procedure.

APG Billing Rate Codes In Effect for January 2010

Service/Setting Facility Type Rate Codes ‐ Effective January 1, 2010
Visit Episode
Outpatient Department * Hospital 1400 1432
OPD ‐ MR/DD/TBI Hospital NA 1489
Ambulatory Surgery Hospital 1401 NA
Emergency Room Hospital NA 1402
School Based Health * Hospital 1444 1450
General Clinic * DTC ** 1407 1422
General Clinic ‐ MR/DD/TBI * DTC 1435 1425
Dental School * DTC 1428 1459
Renal Clinic * DTC 1438 1456
School Based Health * DTC 1447 1453
Free‐standing Surgery Center DTC 1408 NA


* Rate codes being eliminated will continue to be active through December 31, 2009.
** DTC Rate Codes will be effective September 1, 2009 (pending CMS approval), except codes 1453, 1456, and 1459 which are effective 10/1/2009.

Drug and Chemo Reclassifications for January 2010

CPT Description Current APGs New 2010 APGs Description     CPT Description Current APGs New 2010 APGs Description
J0130 Abciximab injection 438 435 Class I Pharmacotherapy     S0156 Exemestane, 25 mg 435 430 Class I Chemotherapy Drugs
J1245 Dipyridamole injection 435 436 Class II Pharmacotherapy S0187 Tamoxifen 10 mg 435 430 Class I Chemotherapy Drugs
J1562 Vivaglobin, inj 435 436 Class II Pharmacotherapy J9380 Vincristine sulfate 5 MG inj 430 431 Class II Chemotherapy Drugs
J2185 Meropenem 435 436 Class II Pharmacotherapy J9291 Mitomycin 40 MG inj 432 431 Class II Chemotherapy Drugs
J0210 Methyldopate hcl injection 435 436 Class II Pharmacotherapy J1327 Eptifibatide injection 431 432 Class III Chemotherapy Drugs
J2248 Micafungin sodium injection 438 436 Class II Pharmacotherapy J8520 Capecitabine, oral, 150 mg 430 432 Class III Chemotherapy Drugs
79005 Nuclear rx, oral admin 436 437 Class III Pharmacotherapy J9120 Dactinomycin injection 430 433 Class IV Chemotherapy Drugs
Q4081 Epoetin alfa, 100 units ESRD 436 437 Class III Pharmacotherapy J9206 Irinotecan injection 434 433 Class IV Chemotherapy Drugs
J1573 Hepagam b intravenous, inj 436 438 Class IV Pharmacotherapy J9170 Docetaxel injection 433 434 Class V Chemotherapy Drugs
J2820 Sargramostim injection 437 438 Class IV Pharmacotherapy J9261 Nelarabine injection 432 434 Class V Chemotherapy Drugs
J2353 Octreotide injection, depot 438 439 Class V Pharmacotherapy J2278 Ziconotide injection 433 441 Class VI Chemotherapy Drugs
J0850 Cytomegalovirus imm IV /vial 439 440 Class VI Pharmacotherapy J9035 Bevacizumab injection 434 441 Class VI Chemotherapy Drugs

NOTE: The aforementioned are examples of drug reclassifications effective January 1, 2010. For a complete list consult the APG website.

New Premium "Class VII" APG for Select Chemotherapy and Pharmacotherapy Drugs

  • There will be a new "premium" drug APG, consisting of certain chemotherapy and pharmacotherapy drugs. All drugs grouping to this class will be carved out of APGs and billable to the Ordered Ambulatory Fee Schedule.
CPT Description Current APGs New 2010 APGs New 2010 APGs
J7311 Fluocinolone acetonide implt 437 442 CLASS VII COMBINED CHEMOTHERAPY & PHARMACOTHERAPY
J1458 Galsulfase injection 439
J1785 Injection imiglucerase /unit 439
J1300 Eculizumab injection 439
J9300 Gemtuzumab ozogamicin inj 434
J0180 Agalsidase beta injection 434

New Mental Hygiene APGs

  • All providers that bill using APGs will have access to the following APG groups:
APG APG Description APG Type Description
321 Crisis Intervention Significant Procedure
322 Medication Administration & Observation *
323 Mental Hygiene Assessment
324 Mental Health Screening & Brief Assessment
274 Physical Therapy, Group
275 Speech Therapy & Evaluation, Group

New APG With Procedure Based Weights and APGs That Recognize Units of Service

  • To recognize significant cost differentials in a single service, some procedures will be paid based on procedure–specific weights rather than APG–specific weight, including the following types of services:
    • Select Mental Hygiene Services,
    • Physical Therapy (for units–based procedures),
    • Occupational Therapy (for units–based procedures), and
    • Crisis Management.

Procedure–based Weights & Units of Service Features in Some APGs

All Procedure–Based and Units–Based APGs
APG APG Description
118* Nutrition Therapy
270** Occupational Therapy
271*** Physical Therapy
272**** Speech Therapy And Evaluation
310 Developmental & Neuropsychological Testing
312 Full Day Partial Hospitalization For Mental Illness
315 Counseling Or Individual Brief Psychotherapy
316 Individual Comprehensive Psychotherapy
317 Family Psychotherapy
320 Case Management & Treatment Plan Development – Mental Health Or Substance Abuse
321 Crisis Intervention
323 Mental Hygiene Assessment
426 Psychotropic Medication Management
427 Biofeedback And Other Training
428 Education – Individual
429 Education – Group
490 Incidental To Medical, Significant Procedure Or Therapy Visit
APG APG Description Payment Action Flag Description HCPCS Code HCPCS code description
118* Nutrition Therapy Alternate Weight – Not Units Based 97804 Medical nutrition, group, each 30 min
G0271 Group MNT 2 or more 30 mins
Alternate Weight – Units Based 97802 Medical nutrition, indiv, each 15 min
97803 Med nutrition, indiv, subseq, each 15 min
G0270 MNT subs tx for change dx, each 15 min
270** Occupational Therapy Alternate Weight – Units Based * 97532 Cognitive skills development, 15 min
97533 Sensory integration, 15 min
271*** Physical Therapy Alternate Weight – Units Based * 97032 Electrical stimulation, 15 min
97033 Electric current therapy, 15 min
272**** Speech Therapy And Evaluation Alternate Weight – Not Units Based 92607 Ex for speech device rx, 1hr
92608 Ex for speech device rx addl

* For illustration purposes only. These APGs include additional procedures not shown in this table.

Medical Visits Will No Longer Package With Higher Intensity Significant Ancillaries

  • Medical visits will no longer package with:
    • more significant ancillaries (e.g., MRIs, mammograms, CAT scans, etc.);
    • dental procedures;
    • PT, OT, and speech therapies; and,
    • counseling services.
  • In these cases, a coded medical visit will separately pay at the line level.

Revised "If Stand Alone, Do Not Pay" List

  • New additions to the "if stand alone, do not pay" list for January 2010 are as follows:
New If Stand Alone Do Not Pay APGs for January 2010
Significant Procedure 118 Nutrition Therapy
Significant Procedure 281 Magnetic Resonance Angiography ‐ Head And/Or Neck
Significant Procedure 282 Magnetic Resonance Angiography ‐ Chest
Significant Procedure 283 Magnetic Resonance Angiography ‐ Other Sites
Significant Procedure 292 Mri‐ Abdomen
Significant Procedure 293 Mri‐ Joints
Significant Procedure 294 Mri‐ Back
Significant Procedure 295 Mri‐ Chest
Significant Procedure 296 Mri‐ Other
Significant Procedure 297 Mri‐ Brain
Ancillary 373 Level I Dental Film
Ancillary 374 Level II Dental Film
Ancillary 375 Dental Anesthesia
Drug 440 Class VI Pharmacotherapy

New (Additional) "No Blend APGs"

  • The following new APGs will pay entirely based on the APG payment methodology and no existing payment will be factored into the operating component of the rate.
APG APG Description APG Type
94 Cardiac Rehabilitation Significant Procedure
310 Developmental and Neuropsychological Testing Significant Procedure
312 Full Day Partial Hospitalization for Mental Illness Per Diem
321 Crisis Intervention Significant Procedure
322 Medication Administration and Observation Significant Procedure
426 Medication Management Ancillary

Additional Significant Program & Policy Changes

Statewide Patient–Centered Medical Home Incentive Program

  • This initiative will incentivize providers for developing patient–centered medical homes to improve health outcomes through better coordination and integration of patient care.
  • New York Medicaid has chosen to adopt medical home standards consistent with the National Committee for Quality Assurance´s (NCQA) Physician Practice Connections® – Patient–Centered Medical Home Program (PPC–PCMH™).
  • The PPC–PCMH™ is a model of care that seeks to strengthen the physician– patient relationship by promoting improved access, coordinated care, and enhanced patient/family engagement.
  • A medical home also emphasizes enhanced care through open scheduling, expanded hours and communication between patients, providers and staff.
  • Care is also facilitated by registries, information technology, health information exchange and other means to ensure that patients obtain the proper care in a culturally and linguistically appropriate manner.
To be recognized as a medical home, providers need to demonstrate they can meet at least five of the following 10 criteria (i.e. achieve a minimum of 25 points out of 100 possible to attain the first of three levels of recognition):
  • Written standards for patient access and patient communication;
  • Use of data to show standards for patient access and communication are met;
  • Use of paper or electronic charting tools to organize clinical information;
  • Use of data to identify important diagnoses and conditions in practice;
  • Adoption and implementation of evidence–based guidelines for three chronic conditions;
  • Active patient self–management support;
  • Systematic tracking of test results and identification of abnormal results;
  • Referral tracking, using a paper or electronic system;
  • Clinical and/or service performance measurement, by physician or across the practice; and
  • Performance reporting, by physician or across the practice.

  • There are three levels of medical home recognition that providers can achieve based on the following NCQA scoring scale:
    PPC–PCMH Scoring
    Level of Qualifying Points Must Pass Elements
    at 50% Performance Level
    Level 3 75 – 100 10 of 10
    Level 2 50 – 74 10 of 10
    Level 1 25 – 49 5 of 10
    Not Recognized 0 – 24 < 5
    Levels: If there is a difference in Level achieved between the number of points and "Must Pass", the practice will be awarded the lesser level; for example, if a practice has 66 points but passes only 7 "Must Pass" Elements the practice will achieve at Level 1.
    Practices with a numeric score of 0 to 24 points or less than 5 "Must Pass" Elements do not Qualify.

  • Medicaid FFS claims with appropriately coded Evaluation and Management (E&M) codes 99201–99205, 99211–99215, or Preventive Medicine codes 99381–99386, 99391–99396 will be eligible for one of three enhanced payment levels (shown below), commensurate with the level of NCQA recognition received by the provider.
    Medical Home Pervisit Payment Add–ons
    Setting Level I Level II Level III
    Article 28 clinics $5.50 $11.25 $16.75
    Office‐based practitioners* $7.00 $14.25 $21.25
    * Includes physicians and registered nurse practitioners
  • NCQA recognized providers that participate in Medicaid and Family Health Plus health plans will receive details on the payment amounts they can expect for services provided to plan enrollees.

Physician Carve Out Policies for OPDs

  • Reimbursement for physician professional services provided by hospital OPDs will be carved out of APGs beginning February 1, 2010.
    • Note, there will be no change to current Medicaid policy which disallows payment for interns and/or residents, yet allows payment for supervisors and/or teaching physicians under specified conditions.

Supporting Materials

  • The following is available on the DOH website
    • Provider Manual
    • PowerPoint Presentations
    • APG Documentation
      • APG Types, APG Categories, APG Consolidation Logic
    • Revised Rate Code Lists
    • Uniformly Packaged APGs
    • Inpatient–Only Procedure List
    • Never Pay and If Stand Alone Do Not Pay Lists
    • Carve–Outs List
    • List of Rate Codes Subsumed in APGs
    • Paper Remittance
    • Frequently Asked Questions
    • Ambulatory Surgery List

Contact Information

  • Grouper / Pricer Software Support
    • 3M Health Information Systems
      • Grouper / Pricer Issues 1–800–367–2447
      • Product Support 1–800–435–7776
      • http://www.3mhis.com
  • Billing Questions
  • Policy and Rate Issues
    • New York State Department of Health
      Office of Health Insurance Programs
      Div. of Financial Planning and Policy 518–473–2160