N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-8.10

Current through Register Vol. 46, No. 51, December 18, 2024

Section 86-8.10 - Exclusions from payment

Payments for the following shall be excluded from rates set pursuant to this Subpart:

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

(b) Visits solely for the purpose of receiving ordered ambulatory services.

(c) Visits solely for the purpose of receiving pharmacy services.

(d) Visits solely for the purpose of receiving education or training services, except with regard to services authorized pursuant to clause (A) of subparagraph (ii) of paragraph (f) of subdivision 2-a of section 2807 of the Public Health Law.

(e) Visits solely for the purpose of receiving services from licensed social workers, except with regard to psychotherapy services provided by Federally Qualified Health Centers or Rural Health Centers subject to reimbursement pursuant to this Subpart, or as authorized pursuant to clauses (C) and (D) of subparagraph (ii) of paragraph (f) of subdivision 2-a of section 2807 of the Public Health Law.

(f) Visits solely for the purpose of receiving group services, except with regard to clinical group psychotherapy services provided by Federally Qualified Health Centers or Rural Health Centers subject to reimbursement pursuant to this Subpart and provided, however, that reimbursement for such group services shall be determined in accordance section 86-4.9(h) of this Part.

(g) Offsite services, defined as medical services provided by a facility's outpatient staff at locations other than those operated by and under the facility's licensure under article 28 of the Public Health Law, or visits related to the provision of such offsite services, except with regard to offsite services provided by Federally Qualified Health Centers or Rural Health Centers and provided, however, that reimbursement for such offsite services shall be determined in accordance with section 86-4.9(i) of this Part.

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

065 RESPIRATORY THERAPY

066 PULMONARY REHABILITATION

117 HOME INFUSION

190 ARTIFICIAL FERTILIZATION

311 FULL DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE

313 HALF DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE

314 HALF DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS

319 ACTIVITY THERAPY

371 ORTHODONTICS

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

443 CLASS VII CHEMOTHERAPY DRUGS

452 DIABETES SUPPLIES

453 MOTORIZED WHEELCHAIR

454 TPN FORMULAE

456 MOTORIZED WHEELCHAIR ACCESSORIES

465 CLASS XIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

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:

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

374 LEVEL II DENTAL FILM

375 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

435 CLASS I PHARMACOTHERAPY

436 CLASS II PHARMACOTHERAPY

437 CLASS III PHARMACOTHERAPY

438 CLASS IV PHARMACOTHERAPY

439 CLASS V PHARMACOTHERAPY

440 CLASS VI PHARMACOTHERAPY

444 CLASS VII PHARMACOTHERAPY

448 AFTER HOURS SERVICES

455 IMPLANTED TISSUE OF ANY TYPE

457 VENIPUNCTURE

460 CLASS VIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

461 CLASS IX COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

462 CLASS X COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

463 CLASS XI COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

464 CLASS XII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

470 OBSTETRICAL ULTRASOUND

471 PLAIN FILM

472 ULTRASOUND GUIDANCE

473 CT GUIDANCE

490 INCIDENTAL TO MEDICAL, SIGNIFICANT PROCEDURE OR THERAPY VISIT

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-8.10