Ambulatory Care Payment Reform - Ambulatory Patient Groups (APGs)

APG Updates

Revised Hospital Base Rates and Existing Operating Payments for Blend

DOH has issued revised hospital base rates and existing operating payments for blend effective July 1, 2009. These revised rates reflect the addition of funds for ancillary services previously billed for hospital patients on an ordered ambulatory basis. For more information on the hospital base rates, capital add-ons and existing payment for blend see the Department's APG website at: http://www.health.state.ny.us/health_care/medicaid/rates/apg/index.htm#rates

Updated Provider Manual

DOH has issued updates to the Ambulatory Patient Group Provider Manual effective July 1, 2009. To review updated policy and billing guidance see the APG Provider manual on the Department's APG website at: http://www.health.state.ny.us/health_care/medicaid/rates/apg/index.htm#manual

New Episode Payment Rate Codes

Starting July 1, 2009, most ancillary laboratory or radiology services associated with a medical visit and/or a significant procedure billed under the APG payment methodology are the fiscal responsibility of the APG provider and must be included on the APG claim, even if the ancillary service is provided by an outside vendor or on a different date of service from the medical visit or significant procedure visit that generated the ancillary service.* Consistent with this change, new rate codes have been issued by eMedNY to hospital OPDs (and will be issued to DT&C clinics upon APG implementation) which will enable the APG Grouper/Pricer to recognize an episode of care as the basic unit of payment. With the episode of care as the basic unit of payment, the APG biller will avoid having to reassign the actual date of service for the ancillary lab or radiology service to correlate with the date of the medical visit or significant procedure that generated the ancillary service.

An episode of care is defined as a medical visit and/or significant procedure that occurred on a single date of service and all the associated ancillary laboratory or radiology services, regardless of the provider or the dates of the ancillary services. The episode payment rate codes permit APG billers to include the actual dates of service at the line level for each lab and radiology ancillary service provided as part of the episode of care. When using episode payment rate codes, APG billers must report the "from" and "to" date in the claim header to reflect the time span for the episode of care and the actual date of service for each service provided at the line level. All procedure codes associated with a medical or significant procedure visit should be reported on a single claim (e.g., one visit plus associated ancillaries = one claim) . If procedures from two different episodes of care are coded on the same claim unwarranted discounting or consolidation may occur resulting in underpayment of the APG biller.

Effective January 1, 2010, hospital OPDs and D&TCs clinic providers will be required to use episode of care rate codes. In the interim, APG billers may use either the appropriate visit based rate codes (1400 for OPD; 1407 for DT&C; 1435 for D&TC- MR/DD/TBI) or the appropriate new episode of care rate codes (1432 for OPD; 1422 for D&TC; 1425 for D&TC-MR/DD/TBI), but not both for the same visit. Visit based rated codes will be end-dated December 31, 2009, for all hospital OPDs and D&TC clinic providers. An episode rate code (1402) is already in effect for hospital emergency departments. New episode rate codes will not be issued for hospital-based or free standing ambulatory surgery claims.

Note: Please note that between July 1, 2009 and August 31, 2009, if an episode claim (1432 rate code) has a time span in the header that overlaps with that of another episode claim for the same patient, the second claim will be denied and no payment will be made by eMedNY. An edit to correct this problem will be implemented by September 1, 2009. This edit will result in use of only the "from" date in the header to identify duplicate claims. Any 1432 claims inappropriately denied as duplicate claims from July 1 through August 31, 2009 may be resubmitted by a hospital after September 1, 2009 once the new edit is in place. Similarly, if a claim with a 1400 rate code is inappropriately denied as a duplicate claim because of the dates used in the header of the claim, hospitals may also rebill these claims after September 1, 2009, once the new edit is in place.

Through eMedNY DOH has issued new episode payment rate codes to hospital OPDs which enable the APG Grouper/Pricer to recognize an episode of care as the basic unit of payment. With the episode of care as the basic unit of payment, APG billers will avoid having to reassign the actual date of service for an ancillary lab or radiology service to correlate with the date of the medical visit or significant procedure that generated the ancillary service in the first instance. The episode payment rate codes permit APG billers to include the actual dates of service at the line level for each lab and radiology ancillary service provided as part of the episode of care.

*Exceptions to the APG Ancillary Billing Policy may be found at the end of Section 4.3 (p.25) of the APG Provider Manual.

For more information on the new Episode Payment see the APG Provider Manual on the Department's APG website at: http://www.health.state.ny.us/health_care/medicaid/rates/apg/docs/apg_provider_manual.pdf

New Date for APG Implementation in Free Standing Diagnostic Treatment Centers and Ambulatory Surgery Centers

DOH has requested a September 1, 2009 approval date from CMS for implementation of APGs in diagnostic and treatment centers and ambulatory surgery centers. If approved by CMS, the revised date will enable the DOH to implement APGs prospectively and avoid the reprocessing of clinic claims back to March 1, 2009. The Department will notify affected D&TC clinic, ambulatory surgery and ancillary providers of CMS approval of the State Plan Amendment immediately upon receipt of such approval. Further instructions on the claiming process will be provided at that time.

FQHC APG Medicaid Reimbursement Option

FQHCs may participate in the APG reimbursement methodology as an "alternative rate setting methodology" as authorized by Public Health Law Section 2807(8)(f). To opt into the APG reimbursement methodology for calendar year 2010, FQHCs must declare their intention by downloading and signing the authorization below. The authorization should be returned to the Department of Health as indicated before November 1, 2009.

Changes in Medicaid Reimbursement to DTCs Providing Services to Medicare/Medicaid Dually Eligible Individuals

Certain designated clinic providers who treat Medicaid enrollees who are developmentally disabled are entitled to receive enhanced reimbursement for Medicare/Medicaid cross-over claims for these enrollees. Instead of the Medicare Part B 20% coinsurance amount, Medicaid pays the higher of the patient responsibility (Medicare deductible/coinsurance) or the difference between the Medicaid rate of payment minus the Medicare payment. These providers have been designated as either Department of Health (DOH) Article 28 Peer Group 41 clinics or Office of Mental Retardation and Developmental Disabilities (OMRDD) Article 16 clinics. Previously, these providers receive the enhanced payment for all dually eligible patients enrolled in their clinic, regardless of whether these patients are developmentally disabled.

Effective July 1, 2009, the following changes have been made for Medicaid reimbursement to DOH clinics for developmentally disabled Medicare/Medicaid dually eligible recipients:

  • Enhanced Medicare cost sharing is no longer be limited to Peer Group 41 clinics, but will be paid to any Diagnostic and Treatment Center (D&TC) providing services to a Medicare/Medicaid dually eligible developmentally disabled individual.
  • The eligible population will be identified using Recipient Exception (R/E) Code 95 (this Recipient Exception code is assigned by OMRDD to recipients who are developmentally disabled).
  • DOH Peer Group 41 providers that formerly received the enhanced cost sharing payment for all dually eligible persons will now receive the enhanced payment only for those dually eligible persons who are assigned R/E Code 95.

D&TC clinic providers can identify recipients who have been assigned R/E code 95. The recipient status should be verified by the provider when recipient Medicaid eligibility is verified.

  • Enhanced Medicare cost sharing will be available for services provided to R/E Code 95 persons billed under the following rate codes (visit based/episode based):
    • 1407/1422 (free-standing general clinic)
    • 1435/ 1425 (Mental Retardation/Developmentally Disabled/Traumatic Brain Injury (TBI) patient in free-standing general clinic) - note: TBI persons will not have R/E code 95 on file and thus will not be eligible for "Medicare maximization"
    • 1428/1459 (dental school)
  • Enhanced Medicare cost sharing does not apply to the following rate codes:
    • 1400/1432 (hospital outpatient department)
    • 1401 (hospital ambulatory surgery)
    • 1402 (emergency department)
    • 1408 (free-standing ambulatory surgery center)
    • 1438/1456 (free-standing renal clinic)
    • 1444/1450 (school-based health clinic affiliated with hospital)
    • 1447/1453 (school-based health clinic affiliated with diagnostic and treatment center)

There is no change in Medicaid payment policy for Article 16 clinics. These clinics will continue to be reimbursed the higher of the patient responsibility (Medicare deductible/coinsurance) or the difference between the Medicaid rate of payment minus the Medicare payment for services provided to dually eligible recipients.

For Medicare/Medicaid eligible recipients in certain Office of Mental Health Programs:

Effective July 1, 2009, Medicare/Medicaid eligible recipients in the Office of Mental Health (OMH) Continuing Day Treatment (CDT) and Prepaid Mental Health Plan (PMHP) programs will also be receiving enhanced Medicare cost sharing payments. The enhanced payments will be reimbursed for services provided by these programs to all Medicare/Medicaid dually eligible recipients. Specifically, cost sharing will be reimbursed at the higher of the patient responsibility (Medicare deductible/coinsurance) or the difference between the Medicaid rate of payment minus the Medicare payment. Medicaid will also continue to pay the higher of the patient responsibility (Medicare deductible/coinsurance) or the difference between the Medicaid rate of payment minus the Medicare payment for clinics licensed by OMH who receive Comprehensive Medicaid Outpatient Programs (COPS) payment.

For Federally Qualified Health Clinic (FQHCs):

There is no change in Medicaid payment policy for FQHCs providing services to dually eligible Medicare/Medicaid recipients. FQHCs will continue to be reimbursed the higher of the patient responsibility (Medicare deductible/coinsurance) or the difference between the Medicaid rate of payment minus the Medicare payment for services provided to dually eligible recipients.

Billing questions on this policy change should be directed to CSC at 1-800-343-3000.

Policy questions should be directed to the Division of Financial Planning and Policy at 518-473-2160.

Implementation of APG payment Methodology delayed for free-standing diagnostic and treatment centers and ambulatory surgery centers

While scheduled for March 1, 2009, implementation of APGs in Diagnostic and Treatment Centers (D&TCs) including free-standing ambulatory surgery centers cannot begin until federal approval is received. The Department has responded to CMS' request for additional information on the State Plan Amendment authorizing federal financial participation for APG payments and has requested a revised implementation date of September 1, 2009. Discussions with CMS are ongoing and approval is anticipated soon.

DT&C providers should continue to submit claims for outpatient services to eMedNY using existing rate codes (not APG rate codes) until further notice. Claims should be fully coded with CPT/HCPCS codes and ICD-9 diagnosis codes. However, D&TCs and ambulatory surgery centers should not include codes for ancillary services (lab and radiology services) currently being billed directly to Medicaid by ancillary service providers, and ancillary service providers should continue to directly bill Medicaid for these services until the new APG payment methodology is implemented.

The Department will notify affected D&TC clinic, ambulatory surgery and ancillary providers of CMS approval of the State Plan Amendment immediately upon receipt of such approval. Further instructions on the claiming process will be provided at that time.

D&TC providers are encouraged to submit test claims to eMedNY. eMedNY's end-to-end test facility permits providers to submit test claims (batches of up to 50 claims) and to receive test remittance advice. Testing prior to the effective date of APG implementation for DT&Cs will help to ensure a smooth transition and provide first-hand experience with the APG claiming process.

For more information on APGs see the Department's APG website at: http://www.nyhealth.gov/health_care/medicaid/rates/apg/index.htm

Questions you may have on APG implementation may be directed as follows:

For Issues/Questions Regarding Please Contact
General Policy,
Rates, Weights
Carve Outs Payment Rules
Implementation Issues		 NYS Department of Health
Office of Health Insurance Programs
Div. of Financial Planning and Policy
518-473-2160
apg@health.state.ny.us
 
Billing Questions
Remittance Questions
Onsite Training re: Billing		 Computer Sciences Corporation
eMedNY Call Center 1-800-343-9000
eMedNYProviderRelations@csc.com
 
Questions Grouper Software/Pricer
Product Support
3M HIS Sales		 3-M Health Information Systems, Inc.
1-800-435-7776
1-800-367-2447
www.3mhis.com

Ambulatory Care Payment Reform - Ambulatory Patient Groups (APGs)

Ambulatory Patient Groups (APGs) is the new payment methodology for most Medicaid outpatient services. APGs will be used to make payments for outpatient clinic, ambulatory surgery and emergency department services, but will not be used initially to cover mental health services and other services carved out of Medicaid managed care for managed care enrollees. Implementation of APGs is just one component of the Department's larger, multi-year agenda to transition funds from inpatient to outpatient services to support quality outpatient care and to address the problem of avoidable hospitalizations.

The State budget agreement for fiscal year 2008-2009 requires the implementation of APGs beginning with hospital-based outpatient and ambulatory surgery department services on December 1, 2008. Emergency department services will be paid using APGs beginning January 1, 2009. Free-standing diagnostic and treatment centers and ambulatory surgery centers will be paid using APGs beginning March 1, 2009. See APG Schedule for more implementation dates.

The full use of APGs to obtain ambulatory care payments will be phased-in over a four-year period. Implementation of APGs is the first major change to the New York Medicaid outpatient reimbursement methodology in more than 20 years and will result in higher payments for higher intensity services and lower payments for lower intensity services across all settings. In addition to payment reform for outpatient services, the 2008-09 Budget provides targeted investments to improve primary care access starting January 1, 2009 including:

  • new coverage for diabetes and asthma education by certified educators in clinic and office based settings;
  • enhanced payment for weekend and evening hours access in both clinic and office based settings;
  • new coverage of smoking cessation counseling for pregnant women; and
  • expanded coverage of psychotherapy counseling by licensed social workers for children, adolescents and pregnant women.

Final Regulations

Chapter 58 of the Laws of 2008 created Section 2807 (2-a)(e) of the Public Health Law which authorizes the Department to adopt and amend rules and regulations, subject to the approval of the State Director of Budget, establishing an Ambulatory Patient Group (APG) 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.

The regulations implement a new payment methodology for certain ambulatory care fee-for-service Medicaid services based on Ambulatory Patient Groups (APGs) and address:

  • categories of facilities subject to APGs and the time frames for implementation;
  • definitions of components of the new reimbursement methodology;
  • requirements for record keeping, reports and audits;
  • the capital cost component to be added to medical payments;
  • conditions for administrative rate appeals;
  • rates for new facilities during the transition period;
  • methodology for establishing base rates;
  • APGs and relative weights;
  • diagnostic coding and rate computation;
  • payments not subject to APG reimbursement;
  • system updating ; and
  • payments for extended hours of operation.

The final regulations are effective upon CMS approval of federal financial participation for the APG payment methodology.

Final Regulations (PDF, 365KB, 63pg.)

APG Known Issues List

APG Training

The Department of Health, along with 3M -- the developer of APGs, Treo Solutions-- the state's consultant, and Computer Sciences Corporation -- the fiscal agent for the NYS Medicaid program, provided training to hospitals accross the State on this important initiative in partnership with the Healthcare Association of New York State (HANYS) and the Greater New York Hospital Association (GNYHA).

Training for free standing diagnostic and treatment centers and ambulatory surgery centers was held on October 29, 2008. This educational session was also accessible through a live Webcast.

These educational sessions covered the following topics:

  • The State's ambulatory care payment reform objectives
  • APG implementation schedule
  • The APG payment methodology
  • Base rate development
  • APG phasing and blending methodology
  • Special policy and payment rules
  • Billing instructions and systems issues
  • Testing schedule

The PowerPoint used for these presentations, the live Webcast, and other implementation materials may be found at:

Implementation Materials

This Web site has been developed to assist Medicaid providers with the upcoming implementation. Please check back regularly as this site will continue to be updated.

Implementation and Training Schedule

Course Date
Hospital APG Training June - July 2008
Final APG Grouper Pricer July 21, 2008
State Plan Amendment to CMS August 1, 2008
Public Comment Period for APG Regulations September 1, 2008
Begin Hospital Provider Testing with eMedNY September 8, 2008
Freestanding D&TCs and Ambulatory Surgery Provider Training October 29, 2008
CMS Approval of State Plan Amendment by December 1, 2008
Implement Hospital-Based Ambulatory Surgery and Outpatient Department APGs December 1, 2008
Freestanding D&TC and Ambulatory Surgery Center Provider Testing with eMedNY December 2008
Implement Hospital-Based Emergency Department APGs January 1, 2009
Implement Primary Care Enhancements January 1, 2009
Implement Freestanding Diagnostic and Treatment Center and Ambulatory Surgery APGs March 1, 2009

Implementation Materials

Training Presentation:

Webcast:

APG Payment Logic:

Crosswalks:

Carve Outs/ Exceptions:

Provider Contact Information:

Policy and Billing Guidance --- APG Provider Manual

The State Department of Health has developed policy and billing guidance to assist providers in understanding and implementing the new APG payment methodology. This document will be updated periodically to provide information on new policy or to add additional clarification as needed.

APG Provider Manual (07-01-09) (PDF, 1.40MB, 50pg.)

Please direct any questions you may have regarding the content of the manual to the APG mail log at apg@health.state.ny.us

Hospital APG Base Rates, Capital Add-Ons, and Existing Payment for Blend

The Department of Health has issued revised APG base rates, provider-specific capital add-ons, and provider-specific hospital clinic existing payment for blend amounts effective July 1, 2009. These revisions, and the initial APG rates, can be found at the following links. Additionally, each of these reimbursement components is described below.

Base Rates

Base rates are service-specific (i.e., hospital clinic, ambulatory surgery, emergency department) and vary by region (upstate and downstate). They were revised for July 2009, based on updated case mix indices, and to include the value of ordered ancillaries associated with clinic and ED patients during 2007 (the current base year). The applicable APG base rate is multiplied by the final allowed APG weight for a visit to determine the full APG operating payment. For clinic services, 25% of this amount is then blended with 75% of the provider-specific existing payment for blend (see description below) to determine the actual operating payment for the visit.

Coding Improvement Factor

A coding improvement factor (CIF) is a numeric value used to adjust the service-specific case mix index used in the calculation of a base rate. The inclusion of a CIF is based on the assumption that the coding of claims will improve over time. For July 2009, hospital CIFs have been revised (reduced) to 1.04 (4%) for hospital clinic services, 1.01 (1%) for emergency department services and 1.00 (0%) for ambulatory surgery services.

Capital Add-Ons

The capital add-on amount is a provider-specific payment that varies between the three hospital-based APG services and that is added to the operating payment for each visit.

Hospital Clinic "Existing Payment for Blend"

The "existing payment for blend" is a facility-specific average rate of payment calculated by dividing all Medicaid revenue (excluding capital add-ons) by all Medicaid visits for services moving to APGs, based on 2007 claims data. For July 2009, the blend payments have been updated to include the provider-specific values for ordered ancillaries associated with clinic patients during 2007 (the current base year). As required by statute, for phase one of APG implementation, 75% of this amount will be included in the payment for each OPD visit, in addition to 25% of the visit-specific APG operating payment amount.

Ambulatory Surgery Procedures List

The ambulatory surgery procedures list includes those HCPCS codes which may be billed against the ambulatory surgery base rate if a hospital provider has an APG ambulatory surgery rate code. The ambulatory surgery procedures list does not mandate the setting in which a procedure may be performed. However, if a visit includes an ambulatory surgery procedure HCPCS code from this list, and the provider has an APG ambulatory surgery rate code, the APG ambulatory surgery rate code should be used on the claim. If the visit does not include a procedure code from the ambulatory surgery procedures list, the claim should be submitted with the APG clinic (OPD) rate code. Claims submitted with the APG ambulatory surgery rate code including multiple visits will be denied if any one visit on the claim does not include a procedure code from the ambulatory surgery list.

This list does not apply to procedures performed in the emergency room. Any procedure performed in the emergency department should be billed using the APG emergency department rate code regardless of the procedures coded.

This list does not obviate the need for DOH certification for those procedures which require certification.

Ambulatory Surgery Procedures List (PDF, 70KB, 47pg.)

Ambulatory Care Payment Reform Contact List

For Issues/Questions Regarding Please Contact
General Policy, Rates Weights, Carve Outs Payment Rules, or Implementation Issues NYS Department of Health Office of Health Insurance Programs Div. of Finanacial Planning and Policy 518-473-2160 apg@health.state.ny.us
Billing Questions Remittance Questions Onsite Training re: Billing Computer Sciences Corporation eMedNY Call Center 1-800-343-9000 eMedNYProviderRelations@csc.com
Questions Grouper Software/Pricer Product Support 3M HIS Sales 3-M Health Information Systems, Inc. 1-800-435-7776 1-800-367-2447 www.3mhis.com

Frequently Asked Questions

1. General Questions

1.1 What are APGs?

Ambulatory Patient Groups (APGs) are a patient classification system designed by 3M Health Information Systems to characterize the amount and type of resources used in an ambulatory care visit for patients with similar clinical characteristics. Use of APGs will result in higher payments for higher intensity services and lower payments for lower intensity services across all settings. APGs were developed to encompass the full range of ambulatory care services including those provided in ambulatory surgery units, hospital emergency rooms and outpatient clinics.

1.2 When will APGs be implemented?

The APGs reimbursement methodology will be phased-in over a four year period. The chart below shows the implementation schedule.

Provider Type Initial Start Date Phase-In
Hospital Outpatient Department December 1, 2008 Starting Dec 1, 2008, 25% of payment will be based on APGs. The percentage will increase to 50% effective Jan 1, 2010; to 75% effective Jan 1, 2011; and to 100% effective Jan 1, 2012.
Hospital Emergency Room January 1, 2009 100% of payment will be based on APGs starting Jan 1, 2009.
Hospital-based Ambulatory Surgery December 1, 2008 100% of payment will be based on APGs starting Dec 1, 2008
Free-standing Diagnostic and Treatment Center March 1, 2009 Starting March 1, 2009, 25% of payment will be based on APGs. The percentage will increase to 50% on Jan 1, 2010; to 75% on Jan 1, 2011; and to 100% on Jan 1, 2012.
Free-standing Ambulatory Surgery March 1, 2009 Starting March 1, 2009, 25% of payment will be based on APGs. The percentage will increase to 50% on Jan 1, 2010; to 75% on Jan 1, 2011; and to 100% on Jan 1, 2012.

Initially, APGs will not be used for Medicaid payment for mental hygiene (mental health, chemical dependence, and developmental disabilities) services, other managed care fee-for-service carved-out services, or for ordered ambulatory services. FQHCs that opt to not utilize the APG payment methodology will also be exempted from APG-based Medicaid payment.

1.3 Does the APG methodology require approval of a State Plan Amendment by the Federal Centers for Medicare and Medicaid Services (CMS)?

Implementation of the APG payment methodology does require federal approval of a State Plan Amendment. Approval is expected by December 1, 2008.

1.4 Once the system is live, what assurance will be in place to ensure that payments are made properly?

Certain edits are built into the claims processing system to ensure that providers submit claims properly. In addition, the State will monitor actual payments against facility specific-projections of payments and providers should be able to do the same.

2. Software and Software Support

2.1 When will the 3M's APG Version 3.1 be available?

3M's Definitions Manual is available at no cost to New York Hospitals through the 3M's Definitions Manual Website. The link to this website is: 3M™ Enhanced Ambulatory Patient Grouping System Definitions Manual

2.2 When will the 3M Grouper/Pricer be available to hospital facilities?

The Grouper/Pricer will be available to providers at the end of July, 2008 as will the specifications for the Grouper/Pricer interface. Questions about the Grouper/Pricer may be directed to 3M at 1-800-367-2447.

2.3 What is the estimated time frame for 3M to train a hospital's IT staff on the software?

3M's training and customer support function is already in place for APGs. If support is needed, call 3M's toll free number 1-800-435-7776.

2.4 Would it be possible for 3M to supply their logic behind the creation of the specific APG?

The APG Logic is included in the 3M Definitions manual which is available to New York hospitals free of charge. See 3M's Definitions Manual website at: 3M™ Enhanced Ambulatory Patient Grouping System Definitions Manual

2.5 How much of the APG pricing will be included in the 3M Grouper versus the Pricer?

The Grouper/Pricer is one integrated software tool. The Grouper component assigns HCPCS codes to APGs; and the Pricer component applies the appropriate weights and base rates to the APGs.

2.6 How often will the APG Grouper/Pricer software be updated?

The APG Grouper/Pricer software will be updated at least two times per year (minimally, once to accommodate updates of ICD-9 diagnosis codes, and once to accommodate updates to HCPCS codes).

3. Systems Issues and Testing

3.1 What is the APG readiness of the eMedNY claims processing system? When can testing begin?

eMedNY will obtain the final Grouper/Pricer from 3M at the end of July, 2008. The eMedNY System is undergoing testing to ensure successful APG implementation in December. Providers will be able to conduct their own APG testing beginning on September 8, 2008.

3.2 What editing will be done with APG claims?

Almost all of the current front end edits used to process clinic claims will remain the same.

  • Additional APG-specific edits are being developed. Editing changes include the use of new MMIS edits including the following:
    • 1. Edit 1044, used when from /to dates on the claim span more than one month;
    • 2. Edit 2001 used when the prior payor amounts in the claim header and line payments don't balance;
    • 3. Edit 1136, used when the rate code is invalid for a clinic; and,
    • 4. Edit 2081, used when all APG claim lines paid zero.

See the APG Implementation PowerPoint Presentation (Slides 118-121 ) for details on how these MMIS edits map to HIPAA 835/277 transactions.

3.3 What information will be included on the remittance form?

The 835 remittance will include line level detail including the APG code, APG full weight, APG allowed percentage, APG paid amount, the payment based on existing operating reimbursement (the blend amount), "combined with CPT" (this field indicates if reimbursement for a particular CPT/APG has been consolidated or packaged within another CPT/APG), capital add-on amount, and the total payment for the claim.

The 835 Companion Guide, which provides detail for all the APG remittance changes, is now available on the eMedNY.org website under NYHIPAADESK.

For providers who receive paper remittances, please see the paper remittance in the APG Implementation PowerPoint Presentation. (See Slides 125-128)

3.4 What are the rules for assigning and paying an APG at the line item detail level? (e.g. APCs currently edit at the detail level and will inform a provider if a specific line should have been bundled and therefore not paid separately.)

All CPT/HCPCS codes claimed for a visit (same date of service) should be included on the claim. The logic in the Grouper/Pricer will assign each line (CPT code) to the appropriate APG at the line level (i.e., every line on the claim will be assigned to an APG, though some may consolidate or package and pay zero at the line level).

3.5 What happens if an individual provider is not ready to bill under APGs by December 1?

Essentially the only change required to bill APGs is the replacement of existing rate codes with new APG rate codes. Hospitals are expected to use the new APG Grouper access rate codes by December 1 on claims for OPD and ambulatory surgery services. If unable to bill APGs on this date, hospitals will have to submit claims, when they can, following the usual Medicaid rules for submission of delayed claims.

For paper claims delayed over 90 days from the date of service, a cover letter for each claim must be attached which specifies one or more acceptable reasons for the delay. Claims submitted electronically must specify the appropriate late submission reason code. For valid coding, refer to the electronic billing instructions http://www.emedny.org/HIPAA/index.html

3.6 How is the existing per-visit payment calculated for purposes of creating the blend (75% at initial implementation) for OPD and DTC claims?

Using 2007 claims data, a facility-specific "average rate of payment" is calculated for OPDs and for D&TCs by dividing all Medicaid revenue by all Medicaid visits for those services moving to APG reimbursement. The percentage of the total payment based on the old reimbursement methodology (e.g., 75% at initial implementation, 50% in 2010, etc.) is then applied to the facility-specific average payment throughout the period of the transition to full payment based on APGs. For further detail please see the APG PowerPoint Presentation (See Slides 80-83).

3.7 Some third party payments are reconciled at the claim line level, while other third party payments are reconciled at the claim header level. How will these payments be shown on the Medicaid invoice for APG payments?

The eMedNY system has been designed to accommodate both third party options. If payments are reconciled at the claim level, the eMedNY system will allocate that information to the line level (paid lines only) and process accordingly. When payments are reconciled at the line level there will be no allocation, and eMedNY will process the line using the information submitted. If a line results in no payment, then the third party payments for that particular line will be bundled with a line that does pay. The 835 electronic remittance will portray the allocation and/or bundling that occurred during processing.

4. Training Questions

4.1 What will SDOH cover in its educational sessions to providers?

Educational sessions for hospital providers were conducted by NYSDOH, 3M, TREO Solutions, and CSC throughout June and July. Issues addressed included: APG policies and principles; APG grouping logic, weighting and pricing; APG carve outs, special payment rules and other APG implementation issues; and APG systems issues and testing schedules. The PowerPoint for this presentation is available here: APG PowerPoint Presentation

4.2 Will training be provided to DTCs and free standing ambulatory surgery centers?

Yes, similar training for free-standing diagnostic and treatment centers and ambulatory surgery centers will be scheduled in fall 2008.

5. Billing / Claims Processing Questions

5.1 What constitutes a clinic visit in terms of services provided during the initial clinic visit, as opposed to ancillary services provided on subsequent days resulting from the initial clinic visit?

A visit will consist of all services listed on a claim document for a single service date. Each unique date of service on a claim will be considered a "visit." Since a claim may contain procedures for multiple service dates, there may be multiple visits on a single claim document.

Reimbursement for some ancillary services provided to assist in patient diagnosis or treatment will always be packaged in the APG payment for a significant procedure or a medical visit, even if the ancillary service is performed on a subsequent day. The list of ancillary procedures always packaged in the APG for a significant procedure or medical visit is referred to as the "Uniform Packaging List" and may be found on the Department's APG website. Uniform Packaging APGs (PDF, 11KB, 1pg.)

5.2 Should same day services be reported on one claim if they occur in more than one outpatient clinic setting on the same date?

1. If the services are provided at a clinic and in the emergency dept. on the same date, they should be reported on separate claim forms. When Medicare is the primary payer, providers may submit one claim for reimbursement of deductibles and coinsurance.

2. If a patient is seen in either the outpatient clinic or ED setting and then has an ambulatory surgery procedure on the same date, all codes associated with both visits should be reported on one claim using the ambulatory surgery rate code.

3. The rule limiting outpatient clinic visits to one threshold visit per day remains in effect under the APG system.

5.3 Medicare presently pays on a monthly basis for certain medical services that occur on a regularly scheduled basis, e.g., renal dialysis, physical therapy. How will APGs accommodate Part B coinsurance/deductible billings for dually eligible enrollees for monthly services?

For monthly billings of Medicare co-pays and deductibles for dual eligibles, continue to use existing rate codes. Do not use APG rate codes for this purpose.

5.4 What should be on a bill?

All claims should include the new APG grouper access rate codes. Claims should include complete and accurate CPT and HCPCS codes and primary diagnosis codes. All services and procedures mapped to an APG claim for the same date of service must be billed together on one claim.

5.5 How are recurring services such as therapies (PT, OT and RT) to be billed?

Each occasion of service is considered a distinct visit. Multiple visits on a single claim will be differentiated by the grouper using the dates of service. Multiple "units of these services on the same date of service will be recognized by the grouper as a single unit. Reimbursement for PT, OT and RT will be based on the average number of units provided per visit on a system-wide basis (reflecting average service intensity), not on the actual number of units billed on the claim.

5.6 How will physicians' services be billed?

Physician services for emergency room and ambulatory surgery visits should be billed on a separate claim using the physician fee schedule. Billing for physician services for OPD visits will follow existing payment policy as stipulated in the physician billing manual (which is based on the treatment of physician costs in the provider's cost report). Physician services for D&TCs are generally included in the APG rate, other than for certain abortion and renal dialysis clinics.

5.7 Are providers still required to bill under Medicaid rate codes such as 2870 for General clinics?

No, this rate code becomes obsolete for dates of service after 12/1/08 for hospital-based OPDs. Providers should use new grouper access rate code 1400 for hospital based OPDs.

Similarly, rate code 1610 will become obsolete for free standing D&TCs after 3/1/09. D&TCs should use new grouper access rate code 1407.

5.8 Will the use of rate codes continue even after the APGs have been fully implemented?

Yes, once APGs are implemented, providers must submit claims using new APG Grouper access rate codes.

Setting Service Old Code1 New Code Effective Date
Hospital OPC/Clinic 2870 1400 12/1/08
Hospital Amb. Surg. 3089 / 3090 1401 12/1/08
Hospital ER 2879 1402 1/1/09
 
Free standing DTC Clinic 1610 1407 3/1/09
Free standing DTC Amb. Surg. 1804 / 1805 1408 3/1/09
Free standing DTC Dental ------- 14282 3/1/09
Free standing DTC MR/DD/TBI ------- 14353 3/1/09
Free standing DTC Renal ------- 14384 3/1/09

REMINDER: Only services listed on your facility's Operating Certificate may be billed.

1 Many other rate codes will become obsolete upon implementation of APGs. For a full list of rate codes subsumed with APG implementation see: http://www.nyhealth.gov/health_care/medicaid/rates/apg/docs/outpatient_rate_codes.pdf (PDF, 157KB, 3pg.)

2 Rate code 1428 will be assigned only to designated dental providers.

3 Rate code 1435 will be assigned to providers who are also assigned rate code 1407 for use in billing for services for recipients with mental retardation, developmental disabilities or traumatic brain injury as indicated by recipient exception codes 81 or 95. Rate code 1435 will not be assigned to providers who only are assigned rate code 1428 or 1438.

4 Rate code 1438 will be assigned to providers in Peer Group 80: statewide dialysis.

5.9 Will the State implement an inpatient-only list similar to Medicare's list of procedures that are only payable if they are performed as an inpatient? Is Medicaid's list the same as that maintained by CMS for APCs?

The NY Medicaid program's "inpatient-only" list is available on the Department's SDOH APG website. Inpatient Only Procedure List (PDF, 56KB, 16pg.) The State's APG Inpatient Only List" is different from CMS' APC "Inpatient Only List." Providers will need to maintain two lists--one for APCs and one for APGs. The APG list allows for more procedures on an outpatient basis.

5.10 Will SDOH issue guidance on the use of modifiers to support multiple services rendered on the same date of service

Guidance on the use of modifiers will be issued shortly.

5.11 How would the system handle an ancillary service on the same date of service as a clinic visit, but not related in any way to that visit?

The cost of "Uniform Packaging Ancillaries" are always included in the initial clinic visit APG, irrespective of the date of service. Ancillaries on the "Never Pay" list will not generate a payment. Other non-packaged ancillaries on the same date of service as a clinic visit will get paid irrespective of ordering date , but only if they are on the same claim. If they are not on the same claim, the second claim will be denied as a duplicate claim.

However, if a community physician not associated with the clinic ordered the ancillary service in the first instance, the ancillary service should be submitted as a separate claim as an ordered ambulatory service. Since this claim will not be filed under an APG rate it will not deny as a duplicate claim.

5.12 Will providers be expected to submit a claim for an ancillary service only?

It is important for providers to submit claims for stand alone ancillaries under APG rate codes, even if they do not expect to get paid. This is important for future re-weighting and possible expansion of coverage for stand alone ancillaries. Ancillary services for clinic patients should never be billed as ordered ambulatory services.

5.13 What is the definition of primary diagnosis code? For example, a patient may present to the ED with chest pain, but the final diagnosis may not be cardiac related, but instead may be determined to be indigestion. Which diagnosis should be entered on the claim? In which field on the electronic 835 does this information reside?

The definition of the primary diagnosis code is the ICD-9 code describing the principal diagnosis (i.e., the condition established after study to be chiefly responsible for occasioning the admission of the patient for care). In the above example, the patient diagnosis should indicate gastric reflux.

Primary diagnosis is included on the electronic X12, 837 in Loop ID 2300: Reference Indicator H101-C022-02; X12 element #-1271; data element qualifier-1270-BK or AFF for ICD-10.

5.14 How will APGs process payments Medicare Part B coinsurance/deductible amounts for patients that have both Medicare and Medicaid coverage?

Under APGs, Medicaid will continue to pay the full Medicare Part B coinsurance and annual deductible amounts.

5.15 SDOH has indicated that it might begin to pay dental clinic claims based upon procedures as opposed to a visit rate. Right now we are paid the same amount under rate code 2870 regardless of procedures. Are we now going to be paid by procedure and if yes, does this mean that we will now need to bill on the HIPAA compliant 837D format as opposed to the institutional 837I?

In the short run, dental services will be paid under a set of dental APGs at the visit level. These dental APG payments will vary based on the intensity of procedures performed, but payment will remain at the visit level. In the future these same APGs may pay at the conclusion of a given procedure rather than at each visit. At that time a new dental rate code may be issued to access the Grouper/Pricer for procedure-based billing. Hospitals will still use the 837I format to claim.

5.16 It is our understanding that some hospital administered drugs that are carved out today (e.g. chemotherapy) will continue to be carved out and billed as ordered ambulatory. It is also our understanding that other drugs will either be paid separately or packaged under APGs and priced based upon Average Wholesale Prices less 15%. Are you expecting the 340B sites to bill you for these drugs as cost and how will you handle this in your grouper or claims edits? We would like clear instructions as to which drugs we should now be including on claims and how.

Physician administered drugs that are carved-out of the APG payment (see APG Carve Outs (PDF, 31KB, 5pg.) for a list of these drugs) should be billed using the fee schedule as ordered ambulatory at the acquisition cost (by invoice) to the hospital provider, including 340B sites. Physician administered drugs not carved-out of the APG payment should be billed as a separate claim line in the clinic claim and will be paid as a component of the APG payment (not acquisition cost).

Payment for Level I drugs is included in the payment for the medical visit or significant procedure and therefore no additional payment is made at the line level. Level II-IV drugs are paid at Average Wholesale Price (AWP) less 15% at the line level by APG. Level I-IV drugs should be claimed as they are now using acquisition cost; however, the APG will be paid at AWP less 15% regardless of cost. 340B sites must bill actual costs.

5.17 Only six modifiers are used in the Grouper/Pricer. What would you do with the other modifiers if they were valued on the claim?

Other modifiers will not affect payment; however, facilities may choose to use them for purposes of following standard coding procedures.

5.18 Will there be a capital add-on for the DTC's?

Yes, it will be the same add-on the D&TC now receives.

5.19 How will the capital add-on for ambulatory surgery be calculated?

The capital add-on for ambulatory surgery services will no longer be based on PAS group. It will be based on the average capital amount facilities are currently receiving as a peer group by region.

5.20 Our physicians do not currently bill Medicaid fee-for-service for ED or ambulatory surgery services. How will our physicians be paid under APGs?

All physician services for hospital-based ambulatory surgery on or after December 1, 2008 and in the hospital emergency department on or after January 1, 2009 must be billed separately by the physician. Payment will be made based on the published Medicaid Physician Fee Schedule. Physicians and physician medical groups who are not already enrolled in fee-for-service Medicaid will need to do so in order to be paid.

5.21 How and what enrollment do we now need to do for physicians in the emergency department and ambulatory surgery. Do we now need to form a physician group for these physicians and do they need a group NPI? Will we need to bill these services on the 837P? The same CPT codes will potentially be on both the physician and the institutional claim so will there be any edit logic, audit or claiming issues?

Emergency department and ambulatory surgery physicians enrolled in Medicaid may bill directly for their services.

If physicians don't have an NPI or are not enrolled in the Medicaid program, they should obtain a NPI and enroll as a participating provider in Medicaid. For more information on how to obtain an NPI, visit https://nppes.cms.hhs.gov. To enroll in Medicaid, visit https://www.emedny.org/info/ProviderEnrollment/index.html. Questions about communicating NPI information to NYS Medicaid should be directed to the eMedNY Call Center at 1-800-343-9000.

Physicians will bill using 837P.

Yes, the same CPT codes will be used on both the physician and institutional claim. Medicaid will pay both the physician and the facility for the Medicaid services provided even though the same CPT/HCPCS codes will appear on both claims. There will not be any edit logic, audit or claiming issues.

5.22 Are part time clinics included in APGs?

Yes - part time clinics will be paid under APG methodology for APG covered services.

5.23 When a patient has multiple significant procedures, some of the significant procedures may require minimal additional time or resources. Significant procedure consolidation refers to the collapsing of multiple related significant procedure APGs into a single APG for payment purposes. Have these significant procedure consolidation decisions been based on clinical factors or claims payment data history?

Significant procedure consolidation decisions have been made by peer physicians using clinical data.

5.24 Effective January 2006, SDOH eliminated the separate EPO rate code ( the presentation documentation still makes reference to this rate code of 3106) and stated that the EPO should be billed as ordered ambulatory and since these charges are typically recorded under the dialysis service itself, we might split the claims. Since there will not be a separate rate code for this or any other carved out lab etc, should they be on the same claim as the associated visit charge (such as EPO with a dialysis visit) or does the APG ancillary charge need to be billed on a separate claim. We need to understand how the system will handle these charges if they are included as a line item on a single claim for that date of service or if they must be separately billed.

Just like the other carved out drugs, bill this ancillary charge on a separate claim as a referred ambulatory service.

6. Primary Care Enhancements

6.1 Would you provide more information on expanded "after hours" access.

Effective January 1, 2009, clinics will receive additional reimbursement for services provided during appointments scheduled on weekends, evenings and holidays. Facilities may bill for these services using the rate codes 1400 or 1407, as appropriate, with the appropriate CPT code -99050 or 99051. Payment will be made through the APG.

6.2 Would you provide more information on mental health counseling by licensed social workers?

Effective January 1, 2009, Article 28 clinics will be reimbursed for mental health counseling provided by licensed social workers (LSW). Reimbursement is limited to counseling provided to children/adolescents (under age 19) and pregnant and postpartum women. Coverage is available for individual and family counseling. Group counseling is not covered.

Pregnancy and pregnancy-related mental health counseling must be accompanied with a primary or secondary diagnosis of pregnancy (ICD codes: 630-677, V22, V23, V28), and up to 60 days with a primary or secondary diagnosis of postpartum depression (ICD codes 6448.4X).

6.3 Will mental health counseling by licensed social workers be reimbursed through an APG?

Counseling by licensed social workers will not be reimbursed through an APG. Three (3) new rate codes will be established: Individual Brief, Individual Comprehensive, and Family Counseling. Claims billed with one of these new rate codes will need to be accompanied with a profession code of LMSW (Licensed Master Social Worker) Profession Code 072 or LCSW (Licensed Clinical Social Worker) Profession Code 073 in order to be paid. Facilities will be notified when the new rate codes become available.

6.4 How will reimbursement for smoking cessation counseling for pregnant women be handled?

Effective January 1, 2009, Medicaid will cover smoking cessation counseling provided to pregnant women. This counseling will complement existing Medicaid covered benefits for smoking cessation coverage, which include prescription and non-prescription smoking cessation products.

  • Eligible beneficiaries are pregnant females who smoke.
  • Claims must have a principle diagnosis of pregnancy (ICD-9-CM Pregnancy Diagnosis Codes: 630-677, V22, V23,V28)
  • Smoking cessation counseling may be provided by a physician, registered physician assistant, registered nurse practitioner, or licensed midwife during a medical visit (no group sessions).
  • Counseling should be billed under rate codes1400 or 1407 with one of the following two CPT codes:
    • 99406-Intermediate smoking cessation counseling, >3 minutes up to 10 minutes.
    • 99407-Intensive smoking cessation counseling, >10 minutes.

6.5 How will diabetes and asthma education be reimbursed?

Effective January 1, 2009, Medicaid will cover asthma and diabetes self-management training.

  • Education services must be ordered by a physician, physician's assistant, nurse practitioner, or licensed midwife.
  • Education services may be provided by NYS licensed, registered, or certified health care professional that is also certified as a diabetes or asthma educator by either the National Certification Board for Diabetes Educators or by the National Asthma Educator Certification Board.
  • Educators must be employed by an Article 28 clinic or an office practice.

A newly diagnosed asthmatic and/or diabetic or one who has a medically complex condition such as exacerbation of condition, poor control of condition, diagnosis of a complication, diagnosis of a co-morbidity, post-surgery, prescription for new equipment, etc. will be allowed up to 20 hours of self-management training during a continuous 12 month period. Asthmatic and/or diabetic enrollees who are medically stable can receive up to 2 hours of self-management training in a continuous 12 month period. Self-management training can be delivered in a group or individual session.

Diabetes self management training should be billed under rate codes 1400 or 1407 with one of the following CPT codes:

  • G0108-Dibetes outpatient self management training services, individual, per 30 minutes.
  • G0109-Diabetes outpatient self management training services, group, per 30 minutes.

Asthma self management training should be billed under rate codes 1400 or 1407 with one of the following CPT Codes:

  • 98960-Individual education for 30 minutes
  • 98961-Group education session, 2-4 patients, 30 minutes
  • 98962-Group education session, 5-8 patients, 30 minutes

6.6 Are the primary care enhancements billable by an Article 28 facility, or are they available only in PPAC clinics?

The primary care enhancements may be provided by an Article 28 facility, as long as they possess the appropriate Health Department certification, e.g., a facility that is offering mental health counseling by licensed social workers must have the authority to do so on their operating certificate.

7. Provider-Specific Questions

7.1. How will School Based Health Clinics be paid under APGs?

School-based health services provided to patients not enrolled in a managed care plan will be reimbursed using APGs. School-based health services provided to managed care enrollees will not be paid using APGs. Managed care carve-out services will continue to be paid fee-for-service by Medicaid under the clinic threshold rate methodology. Previously established rate codes must be used for these billings - rate codes 2888 and 2889.

7.2. How will PAC provider billing be different under APGs? Is the APG grouper different that the PAC grouper?

The APG grouper is different from the PAC grouper. The APG grouping logic is available in the 3M™ Enhanced Ambulatory Patient Grouping System Definitions Manual. The PAC grouper will be replaced by APGs (except for the few FQHCs that remain under the PAC reimbursement methodology).

7.3. How will PAS provider billing be different under APGS?

The PAS grouper will be replaced by the APG grouper and the PAS grouper access rate codes will no longer be used.

7.4 If a medical visit occurs during provision of MMTP services, how is this to be billed under APGs?

All MMTP services, including required medical exams under the MMTP program, should continue to be billed under rate code 2973, Methadone Maintenance Treatment Program, weekly. Medical visits that are distinct from the methadone service can be billed separately under APGs.

7.5 Will FQHCs be subject to APGs?

Pursuant to federal law, FQHCs may choose to be paid under the APG methodology or continue to be paid under the prospective payment system methodology. The payment methodology an FQHC chooses will apply to all claims submitted by the FQHC. For FQHCs that opt for the APG reimbursement methodology, short fall payments for visits provided to Medicaid managed care and FHPlus enrollees will continue to be paid using the existing FQHC shortfall rate codes. The shortfall amount will be based on the FQHC's PPS rate.

Primary Care Enhancements*

The 2008-09 Executive Budget includes a series of initiatives designed to establish or improve access to critical primary and preventive services including:

Mental Health Services by Social Workers will allow Licensed Social Workers (LSW) to bill for mental health counseling services in Article 28 hospital-based clinics for adolescents, children and peri-natal populations.

Asthma & Diabetes Self Management Education will allow for asthma and diabetes self-management training services for persons diagnosed with diabetes and/or asthma in clinics and office based settings when such services are ordered by a physician, registered physician's assistant, registered nurse practitioner, or a licensed midwife and are provided by a New York State licensed, registered, or certified health care professional who is also a certified diabetes or asthma educator.

Expanded After Hours Access will offer an enhanced payment for office-based physician and clinic services rendered outside of normally scheduled hours, e.g. during the evening, on weekends, or on a holiday in addition to basic service.

Smoking Cessation will provide smoking cessation counseling to pregnant women. This counseling will complement existing Medicaid covered benefits for smoking cessation coverage, which include prescription and non-prescription smoking cessation products, and access to the New York State Smoker's Quit Line.

*Additional NYS Medicaid policy guidance will be available in an upcoming Medicaid Update edition.

We welcome your questions. Please e-mail us at apg@health.state.ny.us