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DOH EAPG Base Rates Effective Date NYS WCB EAPG Base Rates 2015 DOWNSTATE UPSTATE DOWNSTATE UPSTATE Ambulatory Surgery Hospital 1401/1416 $197.29 $152.41 (Effective Jan. 1, 2011 Forward) $295.94 $228.62 Ambulatory Surgery Freestanding 1408 $116.24 $101.18 Phase I APG Base Rates (Effective Jan. 1, 2010 Forward) $295.94 $228.62
- Introduction and Overview
- 3M™ Enhanced Ambulatory Patient Grouping System
- APG Payment Methodology and Payment Examples
- EAPG Relative Weight Process
- Singleton Examples
- APG Base Rate Development
- APG Phasing and Blending Methodology
- APG Carve-Outs and Special Payment Rules
- Other APG Implementation Issues
- Billing Instructions and System Issues
Background
1. Existing Medicaid outpatient rate methodologies are broken, most payments are capped and ambulatory surgery rates are outdated. 2. For example, most hospital clinic rates are capped at $67.50 plus capital resulting in a fixed payment methodology which fails to recognize variation in service intensity thereby discouraging the provision of higher intensity care. 3. By failing to keep pace with the cost of care and medical advances, the current ambulatory care rates do not appropriately pay p...
Reform Objectives
1. Encouragemigration of services from inpatient to ambulatory/primary care settings. 2. Investin ambulatory care to provide more adequate reimbursement. 3. Developa new payment system to pay more for higher cost services and less for lower cost services. 4. Ensurebetter payment homogeneity for similar/comparable services across ambulatory care settings. 5. Improvedclarity and transparency of payment structure and methodology. 6. Frequentpayment updates to recognize medical advances and chang...
APG´s Fiscal Benefits
1. $57M investment for hospitals in SFY 08/09. 2. $178M full annual investment in SFY 09/10. 3. Growing to $418M by year four (requires inpatient rebasing and reinvestment). 4. For OPD, AS, and ED combined, average year one increase per visit is $45. Average year four increase per visit is $103. 5. Average percentage increase in payment of 40% in year one. Average year four increase in payment of 90%. 6. Assuming constant volume, average year one ambulatory payment increase of $850,000 per ho...
EAPGs vs DRGs
1. DRGs 1.1. Describes an inpatient admission 1.2. Uses discharge date to define code sets 1.3. Based only on ICD-9-CM codes 1.4. Each admission assigned only 1 DRG 2. EAPGs 2.1. Defines ambulatory visit 2.2. Uses date of service to define code sets 2.3. Based on ICD-9-CM Dx and HCPCS Px codes 2.4. Multiple EAPGs may be assigned per visit
Data set for defining EAPGs
1. EAPG 1.1. ICD-9-CM diagnosis (Dx) codes 1.2. HCPCS level I & level II procedure (Px) codes 1.3. HCPCS level I modifiers 1.3.1. 25 distinct service 1.3.2. 27 multiple E/M visits, same date 1.3.3. 52 terminated ("reduced") px 1.3.4. 73 terminated px 1.3.5. 59 separate px 1.3.6. 50 bilateral px 2. Gender
APG Payment Definitions
1. Consolidation (a.k.a., "Bundling")- The inclusion of payment for a related procedure in the payment for a more significant procedure provided during the same visit. 2. Packaging - The inclusion of payment for related ancillary services in the payment for a significant procedure or medical visit. 2.1. The majority of "Level 1 APGs" are packaged in New York State. 3. Discounting- A discounted payment for an additional, but unrelated, procedure provided during the same visit to acknowledge co...
Six Basic Steps
1. Define Data Set 2. Cost Development 3. Group Data 4. Singletons 5. Calculate Average Costs/Weights 6. Validate 1. Define Data Set 1.1. 2005 Hospital Outpatient MMIS data 1.2. 2005 Referred Ambulatory MMIS data 2. Determine Data Sources 2.1. ER, Amsurg, and Hospital-based Clinic 3. Determine Services to be Paid Under APGs 3.1. First, includeclaimswith approved rate codes from DOH. 3.2. Then, excludelines outside the scope of EAPGs 3.2.1. i.e. Per Diems, DME, etc. 1. Determine Ratio of Cost...
APG 574 - Chronic Obstructive Pulmonary Disease
1. Relative Weight 1.1. Measure of the resource intensity of an APG relative to other APGs in a specific data set. 2. Determine Average Cost for Each EAPG 2.1. = Σ of APG costs/ Σ of APG Visits 3. Determine Average Cost for All EAPGs 3.1. = Σ of all singleton costs/ Σ of all singleton visits 4. Determine EAPG Relative Weight 4.1. = APG Average Cost /Average Cost for all singletons
Relative Weight Example
1. Benchmark Results: 1.1. Null volume 1.2. Low volume 1.3. Single provider APGS 1.4. Overall reasonableness of weights 2. Data Sources: 2.1. Meds II 2.2. Referred Amb 2.3. Referred Drug 2.4. Treo Commercial 3. Minimal claims affected through adjustments
APG Base Rates
1. Base rates are established for peer groups based on one or more of the following factors: 1.1. Service Type (OPD, ED, Amb Surg, Free-Standing Clinic, Free-Standing Amb Surg) 1.2. Region (Upstate, Downstate) 1.3. Procedure (Dental)
APG Base Rate Regions
1. Downstate - New York City, Nassau, Suffolk, Westchester, Rockland, Putnam, Dutchess, Orange 2. Upstate - The rest of the State
Base Rate Variables
1. Case Mix Index (CMI) 2. Coding Improvement Factor (CIF) 3. Visit Volume 4. Targeted Expenditure Level 4.1. Base Year Expenditures 4.2. Investment 5. Reported Provider Cost by Peer Group (for scaling of investments)
Hospital OPD and DTC Transition and "Blend"
Ambulatory Surgery and Emergency Department will not be transitioned and instead will move to 100% APGs immediately, Amb Surg on 12/1/08 and ED on 1/1/09.
Calculation of the Existing Per-Visit Payment - for Purposes of Creating the Blend
1. The "blend" applies only to OPD. 2. Both Ambulatory Surgery and Emergency Department move to 100% APG payment upon implementation (no blend). 3. Calculated using CY 2007 claims data. 4. Frozen throughout the period of the phase-in. 5. Using all OPD (clinic) MA revenue divided by all OPD MA visits - for services moving to APG reimbursement (excludes mental hygiene).
APG Visit Carve-Outs
1. All items currently carved-out of the threshold visit rate will continue to be carved-out and paid off the referred ambulatory services fee schedule - with a single exception …. 1.1. MRIs will no longer be carved-out of the threshold visit, but instead must be billed under APGs. 2. For a complete list of all APG carve-outs, including all drugs designated as chemo drugs, see carve-outs handout.
Chemo Drugs are all Carved-Out
1. Chemotherapy drugs were previously carved-out of the threshold rate only for patients billed to the oncology specialty rate code 3092. 2. All chemo drugs will be carved-out of APG billing for all patients. These drugs will be billable as referred ambulatory services. 3. The definition of a chemo drug will be any drug that groups to one of the five chemo drug APGs. 4. Some of these drug have codes that do not begin with "J9" and may have other uses besides treating cancer. Nevertheless, any...
Billing for Drugs
1. Drugs carved out of APGs will be billed against the referred ambulatory fee schedule 2. For drugs in APGs: 2.1. Class 1 Pharmacotherapy drugs will be packaged, so the costs will be included in the weight of the primary APG (significant procedure or medical visit) 2.2. Drugs in Pharmacotherapy Classes 2 through 5 will be priced based on the Average Wholesale Prices (less 15%) of the drugs found in each group (this is consistent with the payment for drugs on the referred ambulatory fee sched...
PACs
1. Last Updated over sixteen years ago 2. All inclusive pricing 3. Not reflective of new medical advances or technologies 4. Ancillary pricing based upon outdated survey material 5. Pricing based upon the "average visit" within a PAC group 6. ICD_9 diagnosis code driven 7. Visits are not weighted for intensity 8. Effective December 1, 2008, PACs will be replaced by APGs (except for FQHCs - see next slide)
FQHCs and APGs
1. Facility may choose to be paid under the APG methodology, or under the existing prospective payment system rate methodology 2. The payment methodology selected by the FQHC would apply to all claims submitted. 3. For FQHCs that switch to APG reimbursement, FQHC wraparound (shortfall) payments will continue to be paid - using the existing FQHC shortfall rate codes. 4. PAC rates will continue to be available as a payment mechanism only for FQHCs that opt to continue using them instead of swit...
Inpatient Only
1. Inpatient care will continue to be paid under DRGs. 2. Certain specific surgical procedures identified within 3M the grouper / pricer (see handout) must be done on an inpatient basis only. 2.1. These procedures may not be performed on an ambulatory surgery or on a clinic outpatient basis.
Provider Billing Changes
1. New Rate Codes Effective 12/1/08 Dates of Service 1.1. New APG Grouper Access Rate Codes: 2. Hospital Based Outpatient Rate Code 1400 3. Hospital Ambulatory Surgery Rate Code 1401 4. New Rate Code Effective 1/1/09 Dates of Service 4.1. New APG Grouper Access Rate Code: 4.1.1. Hospital Emergency Room Rate Code 1402 5. Most current Rate Codes will become obsolete as of APG effective date 5.1. See Rate Code List Handout 5.1.1. For billing or adjusting dates prior to 12/1/08 use old rate code....
Editing Changes
1. MMIS Edit 1044 1.1. From/To Dates may not span months DOS Cannot Span Across Months 2. HIPAA 835/277 Mapping 2.1. Adjustment Reason Code 16: Claim/Service lacks information which is needed for adjudication 2.2. Remit Remark Code N74: Resubmit with multiple claims, each claim covering services provided in only one calendar month 2.3. Status Code 188: Statement from-through dates 3. MMIS Edit 2001 3.1. Prior payer paid amounts Claim Header and Line Payments must balance 4. HIPAA 835/277 Mapp...
Processing Changes
1. "Family Planning Benefit ProgramONLY" Client Claims 1.1. Procedures not included in FP covered list will not group to an APG nor have a price applied 1.2. (Submit all procedures & non-FP procedures ignored) 1.2.1. FP List - See Medicaid Update February 2008 2. Allocating Medicare/Other Insurance 2.1. Deductible, coinsurance, copays 2.2. If only reported at header of claim 2.3. Amounts from header allocated to lines 2.3.1. Sum of APG payments for all lines 2.3.2. Individual line payments di...
People also ask
Where can I find the eapg definitions manual?
Can eapg & significant procedure be performed on same day?
What is eapg discounting?
What are eapgs & how do they work?
Jan 1, 2024 · Note: The APG reimbursement methodology pre-existed New York State´s (NYS) APG implementation. The 4/1/2008 thru 7/1/2009 effective dates above are for the version of APG methodology and may not relate to NYS´ implementation dates for APGs. For NYS implementation dates of APGs, return to the APG Home page. Revised: February 2024.
Rates of payment for out-of-state providers in counties contiguous to New York City and New York’s Dutchess, Putnam, Westchester, Rockland and Orange Counties will reflect the average Ambulatory Patient Group (APG)
EAPG Appendix A — NYS Workers’ Compensation Specific Base Rates Service Type *Base Rate Visit Code NYS DOH EAPG Base Rates Base Rate Effective Date NYS WCB EAPG Base Rates July 15, 2019 DOWNSTATE UPSTATE DOWNSTATE UPSTATE Emergency Department 1402 $197.38 $154.15 May 1, 2012 $296.07 $231.23
A patient with a significant procedure or a medical visit may have ancillary services performed as part of the visit. Ancillary packaging refers to the inclusion of certain ancillary services into the EAPG payment for a significant procedure or medical visit. Below is a uniform list of ancillary EAPGs that are always packaged into a significant ...
NYS OMH EAPG Base Rates Base Rate Effective Date NYS WC EAPG Base Rates July 15, 2019; DOWNSTATE UPSTATE DOWNSTATE UPSTATE; Base Rate: 1516: $181.16: $139.25: April 1, 2019: $181.16: $139.25: Off-site Base Rate (available for select children's services and crisis- brief for both adult and children.) 1519: $181.16: $139.25: April 1, 2019: $181. ...
