N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-8.9

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

Section 86-8.9 - Diagnostic coding and rate computation

(a) Facilities shall assign ICD-9 diagnostic codes and HCPCS/CPT procedure codes to each claim as appropriate and shall submit such information to the department or the department's designee in accordance with written billing and reporting instructions issued by the department. the department shall utilize such claim coding information to assign each the applicable APG or APGs for each patient visit identified on the claim, utilizing the APG software system to determine the significant procedure APG or the medical visit APG, the applicable ancillary services APGs and the final APG weight applicable to each such visit. the APG software system shall incorporate methodologies for consolidation, packaging and discounting to be reflected in the final APG weight to be assigned to each visit on the claim.

(b) The operating component of the payment rate for each patient shall be computed by multiplying the final APG weight for each visit, as computed in accordance with subdivision (a) of this section, by the applicable base rate, as determined in accordance with section 86-8.7 of this Subpart. A capital component shall then been added to each such payment rate in accordance with the provisions of section 86-8.4 of this Subpart.

(c) Drugs purchased under the 340B drug benefit program and billed under the APG reimbursement methodology shall be reimbursed at a reduced rate comparable to the reduced cost of drugs purchased through the 340B drug benefit program.

(d) In cases where the only reimbursable APGs for a visit are one or more of the following APGs, there shall be no reimbursement for capital costs included in the payment for that visit.

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

451 SMOKING CESSATION TREATMENT

(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 & Neuropsychological Testing

312 Full Day Partial Hospitalization for Mental Illness

321 Crisis Intervention

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

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-8.9