Ambulatory Patient Group (APG) Regulations

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
  1. The APGs and each associated relative weight are:
    January 2010 APG Weights
    APG 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
  2. 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 Ceroalo
New York State Department of Health
Bureau of House Counsel, Regulatory Affairs Unit
Corning Tower Building, Rm 2438
Empire State Plaza Albany, New York 12237
(518) 473–7488
(518) 473–2019 (FAX)
REGSQNA@health.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.

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