New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Limitation on Hospital Stay › Section 85.6 - Admissions and hospital stays

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Inpatient hospital admissions which do not require a determination of benefit
					 coverability under sections
					 85.1 through
					 85.4  of this Part and except for
					 admissions under subdivision (f) of this section shall be deemed a covered
					 benefit under medical assistance for the needy as provided in section 365-a (2)(b)  of the Social Services Law for the first three days of inpatient
					 hospital care. To be a covered benefit after the third day of inpatient
					 hospital care, there shall be a determination of benefit coverability prior to
					 the end of the third day by a person designated by the Commissioner of Health.
					 Such determination shall be for a specified period of time not to exceed the
					 50th percentile of length of stay norms for comparable patients which have been
					 authorized by the Commissioner of Health or the 20th day of stay, whichever is
					 less. If the stay is for rehabilitation of physical disability as described in
					 subdivision (a) of section
					 85.5  of this Part, such specified
					 period of time shall not exceed the 40th day of stay. Determination of
					 coverability shall be based upon existence of medical conditions which can be
					 treated only on an inpatient hospital basis, as documented in the patient's
					 medical record. Subsequent to this initial determination of coverability,
					 extensions of benefit coverability shall be subject to length of stay
					 limitations of sections
					 85.5 and
					 85.7  of this Part.
(b) A determination of benefit coverability
					 under this section shall be made by a designated physician or nonphysician
					 under a designated physician's supervision. A determination of noncoverability
					 shall be made only by a designated physician. If such determination of
					 noncoverability is made, any inpatient hospital care, supplies or services
					 provided beyond three days shall not be a covered benefit under medical
					 assistance for the needy.
(c)
					 Notice of determination shall be given to the patient's physician, the hospital
					 administrator and, if there is a determination of noncoverability, to the
					 patient.
(d) The patient's
					 physician or hospital administrator may, within three days of the date of such
					 notification, appeal a determination of noncoverability in writing to the
					 physician or physicians designated by the commissioner for such purpose.
					 Notification of the decision on appeal shall be given to the patient's
					 physician, the hospital administrator and the patient. If determination of
					 noncoverability is affirmed on appeal, any inpatient hospital care, supplies or
					 services provided beyond three days shall not be a covered benefit under
					 medical assistance for the needy.
(e) If the person designated by the
					 Commissioner of Health decides in the course of making determinations of
					 coverability under this section or it is determined from other sources that a
					 physician, physicians or the hospital are admitting patients for medical
					 conditions which can be treated on other than an inpatient hospital basis, the
					 designated person shall give written notification to the physician(s) and the
					 hospital that if such admissions continue, the initial three-day period of stay
					 will no longer be deemed a covered benefit. If patients are thereafter admitted
					 for medical conditions which can be treated on other than an inpatient hospital
					 basis, the designated person shall notify the physician(s) and the hospital
					 that to be a covered benefit, the first three days of inpatient stay will be
					 subject to a determination of coverability. Such determination of coverability
					 shall be made prior to the end of the third day of inpatient hospital stay in
					 accordance with the procedures in subdivisions (a) through (d) of this section.
					 If there is a determination of noncoverability, any inpatient hospital care,
					 supplies or services provided shall not be a covered benefit under medical
					 assistance for the needy.
(f)
(1) During such period of time as sections
					 85.2 and
					 85.3  of this Part do not apply,
					 all surgery, other than emergency or urgent surgery, within "medical
					 assistance" as defined in section 365-a  of the Social Services Law, shall
					 require a determination of coverability by a person designated by the
					 Commissioner of Health prior to admission. A determination of coverability
					 shall be based on a finding that the proposed surgery can be performed properly
					 only on an inpatient hospital basis.
(2) A determination of coverability shall be
					 for a specified period of time not to exceed the 50th percentile of length of
					 stay norms for comparable patients which have been authorized by the
					 commissioner or the 20th day of stay, whichever is less. If the stay is for
					 rehabilitation of physical disability as described in section
					 85.5(a)  of this
					 Part, such specified period of time shall not exceed the 40th day of stay.
					 Subsequent to this initial determination of coverability, extensions of benefit
					 coverability shall be subject to length of stay limitations of sections
					 85.5 and
					 85.7  of this Part.
(3) The required determination of
					 coverability shall be initiated by written request from the proposing surgeon,
					 with information adequate for making the determination. A determination of
					 coverability shall be made by a designated physician or nonphysician under
					 supervision of a designated physician. A determination of noncoverability shall
					 be made only by a physician.
(4)
					 Notice of determination shall be given to the proposing surgeon who shall, if
					 coverability is determined, incorporate such notice in the hospital record at
					 admission.
(5) The proposing
					 surgeon may appeal any determination of noncoverability to a physician or
					 physicians designated by the Commissioner of Health for such purpose.
					 Notification of decision on appeal shall be given to the proposing surgeon who
					 shall incorporate any notice of determination of coverability in the hospital
					 record at admission.
(6) Admissions
					 and hospital stays solely for the purpose of performing any procedure which may
					 be performed on an outpatient basis, as defined in paragraph (7) of this
					 subdivision, shall not be included as inpatient care in a hospital or care in a
					 hospital-based ambulatory surgery service or a free-standing ambulatory surgery
					 center for purposes of coverability of benefits except that a determination of
					 coverability may be made by a person designated by the Commissioner of Health
					 when the medical condition of the individual patient requires that such
					 procedure be performed on an inpatient basis in a hospital or as care in a
					 hospital-based ambulatory surgery service or a free-standing ambulatory surgery
					 center. For inpatient hospital, hospital-based ambulatory surgery service and
					 free-standing ambulatory surgery center admissions for certain surgical
					 procedures, as defined in paragraph (7) of this subdivision there shall be a
					 determination prior to admission of the specified period of coverability as
					 provided for in this subdivision, except for emergency admissions for which the
					 determination of the period of coverability shall be made as soon after
					 admission as feasible.
(7) A
					 procedure which may be performed on an outpatient basis ("outpatient
					 procedure"), is a diagnostic test or treatment, including certain surgical
					 procedures, that carries a low patient risk, requires minimal preand
					 post-procedure observation and treatment, is not likely to be time consuming or
					 followed by complications, and is not associated with a condition which would
					 require hospitalization. Column (1) lists "The International Classification of
					 Diseases, 9th Revision, Clinical Modification" (ICD-9 CM) procedure codes for
					 outpatient surgery and column (2) below lists the outpatient surgical
					 (ICD-9-CM) procedure names. Such outpatient procedures include, but are not
					 limited to, the following:
(1)
(2)
ICD-9-CM Procedure
								  Code
ICD-9-CM Procedure
									 Name
(i) 3.31
Spinal tap
(ii) 8.09
Other eyelid incision
(iii) 8.11
Eyelid biopsy
(iv) 8.20
Removal of lesion of eyelid, NOS
(v) 8.21
Excision of chalazion
(vi) 8.22
Excision of other minor lesion of eyelid
(vii) 8.41
Repair entrop/ectro-thermocauterization
(viii) 8.42
Repair entrop/ectro. by suture tech.
(ix) 8.52
Blepharorrhaphy
(x) 18.09
Other incision of external ear
(xi) 18.21
Excision of preauricular sinus
(xii) 18.29
Excis./destruct. of other lesion ext. ear
(xiii) 20.09
Other myringotomy
(xiv) 21.21
Rhinoscopy
(xv) 21.22
Biopsy of the nose
(xvi) 21.30
Excis./destruct. of lesion-nose, NOS
(xvii) 21.31
Local excsn./destruct.-intranasal lesion
(xviii) 21.32
Local excsn./destruct.-other lesion of nose
(xix) 21.61
Turbinectomy by diathermy or cryosur
(xx) 21.69
Other Turbinectomy
(xxi) 23.01
Forceps extraction of deciduous tooth
(xxii) 23.09
Forceps extraction of other tooth
(xxiii) 23.11
Surgical removal of residual root
(xxiv) 23.19
Other surgical extraction of tooth
(xxv) 23.20
Restoration of tooth by filling
(xxvi) 23.30
Restoration of tooth by inlay
(xxvii) 23.41
Application of crown
(xxviii) 23.42
Insertion of fixed bridge
(xxix) 23.43
Insertion of removable bridge
(xxx) 23.49
Other dental restoration
(xxxi) 23.50
Implantation of tooth
(xxxii) 23.60
Prosthetic dental implant
(xxxiii) 23.70
Root canal, NOS
(xxxiv) 23.71
Root canal therapy with irrigation
(xxxv) 23.72
Root canal therapy with apicoectomy
(xxxvi) 23.73
Apicoectomy
(xxxvii) 24.00
Incision of gum or alveolar bone
(xxxviii) 24.11
Biopsy of gum
(xxxix) 24.12
Biopsy of alveolus
(xl) 24.19
Other diag. proc. on teeth, gums
(xli) 24.20
Gingivoplasty
(xlii) 24.31
Excision of lesion of tissue of gum
(xliii) 24.32
Suture of laceration of gum
(xliv) 24.39
Other operations on gum
(xlv) 24.40
Excision of dental lesion of jaw
(xlvi) 24.50
Alveoloplasty
(xlvii) 24.60
Exposure of tooth
(xlviii) 24.70
Application of orthodontic appliance
(xlix) 24.80
Other orthodontic operation
(l) 24.91
Extension or deepening of buc. sulcus
(li) 24.99
Other dental operations
(lii) 25.02
Open biopsy of tongue wedge biopsy
(liii) 25.10
Excisn./destuctn lesion/tissue tongue
(liv) 27.43
Other excision of lesion/tissue lip
(lv) 27.49
Other excision of mouth
(lvi) 27.59
Other plastic repair of mouth
(lvii) 31.42
Laryngoscopy and other tracheoscopy
(lviii) 45.24
Flexible sigmoidoscopy
(lix) 48.23
Rigid Proctosigmoidoscopy
(lx) 48.25
Open biopsy of rectum
(lxi) 49.23
Anal biopsy
(lxii) 49.30
Loc. excsn./dest. oth. lesion/tissue of anus
(lxiii) 49.45
Hemorrhoid ligation
(lxiv) 49.47
Evacuation of thrombosed hemorrhoid
(lxv) 56.91
Ureteral meatus dilation
(lxvi) 57.19
Other cystostomy
(lxvii) 57.32
Other cystoscopy
(lxviii) 57.33
Closed (transur) biopsy of bladder
(lxix) 57.94
Insertion of indwelling urinary cath
(lxx) 57.95
Replacement-indwelling urinary cath
(lxxi) 58.10
Urethral meatotomy
(lxxii) 59.80
Urethral catheterization
(lxxiii) 83.21
Biopsy of soft tissue
(lxxiv) 86.04
Other incsn w/drainage of skin/ subcu. tissue
(lxxv) 86.11
Biopsy of skin & subcutaneous tissue
(lxxvi) 86.22
Excision debrid of wound infection or burn
(lxxvii) 86.23
Removal of nail, nailbed, nail fold
(lxxviii) 86.25
Dermabrasion
(lxxix) 86.59
Suture skin/subcut. tissue of other sites
(lxxx) 88.66
Phlebography-femoral, other lower extrm vein c.
								  material
(lxxxi) 89.26
Gynecological examination
(lxxxii) 97.71
Remove intrauterine contraceptive device
(8) Admissions and hospital stays solely for
					 the purpose of performing any procedure which may be performed on an ambulatory
					 surgery basis as defined in paragraph (9) of this subdivision, shall not be
					 included as inpatient care in a hospital for purposes of coverability of
					 benefits except that a determination of coverability may be made by a person
					 designated by the Commissioner of Health when the medical condition of the
					 individual patient requires that such procedure be performed on an inpatient
					 basis in a hospital. For inpatient hospital admissions for procedures listed in
					 paragraph (9) of this subdivision, there shall be a determination prior to
					 admission of the specified period of coverability as provided for in this
					 subdivision, except for emergency admissions for which the determination of the
					 period of coverability shall be made as soon after admission as
					 feasible.
(9) A procedure which may
					 be performed on an ambulatory surgery basis ("ambulatory surgery procedure"),
					 is a diagnostic test, treatment, or procedure which shall be performed for
					 safety reasons in an operating room on anesthetized patients requiring a stay
					 of less than 24 hours' duration. These procedures do not include outpatient
					 office or outpatient treatment room procedures as defined in and covered by
					 paragraph (7) of this subdivision. Column (1) below lists the "The
					 International Classification of Diseases, 9th Revision, Clinical Modification
					 (ICD-9-CM) procedure names for ambulatory surgical procedures and Column (2)
					 lists the ICD-9-CM procedure codes for ambulatory surgical procedures for which
					 prior approval is necessary for inpatient hospital admission, except for
					 emergency admissions for which the determination of the period of coverability
					 shall be made as soon after admission as feasible. Such ambulatory surgery
					 procedures include, but are not limited to the following:
(1)
(2)
ICD-9-CM Procedure
									 Names
ICD-9-CM Procedure
								  Codes
(i)
spinal tap
03.31
(ii)
other excision or avulsion of cranial and
								  peripheral nerves
04.07
(iii)
release of carpal tunnel
04.43
(iv)
other peripheral nerve or ganglion decompression or
								  lysis of adhesion
04.49
(v)
excision of pterygium
11.39
(vi)
intracapsular extraction of lens by temporal
								  inferior route
13.11
(vii)
other intracapsular extraction of lens
13.19
(viii)
extracapsular extraction of lens by simple
								  aspiration (and irrig.) technique
13.3
(ix)
extracapsular extraction of lens by temporal
								  inferior route
13.51
(x)
other extracapsular extraction of lens
13.59
(xi)
insertion of pseudophakos, NOS
13.70
(xii)
insertion of intraocular lens prosthesis at
								  cataract extraction, 1-stage
13.71
(xiii)
secondary insertion of intraocular lens
								  prosthesis
13.72
(xiv)
recession of one extraocular muscle
15.11
(xv)
advancement of one extraocular muscle
15.12
(xvi)
resection of one extraocular muscle
15.13
(xvii)
other operation on one extraocular muscle involving
								  temporary detachment from globe
15.19
(xviii)
lengthening procedure on one extraocular
								  muscle
15.21
(xvix)
shortening procedure on one extraocular muscle
15.22
(xx)
other operations on one extraocular muscle
15.29
(xxi)
operations on two or more extraocular muscles
								  involving temporary detachment from globe, one or both eyes
15.3
(xxii)
excision or destruction of other lesion of ext.
								  ear
18.29
(xxiii)
myringotomy with insertion of tube
20.01
(xxiv)
other myringotomy
20.09
(xxv)
submucous resection of nasal septem
21.5
(xxvi)
closed reduction of nasal fracture
21.71
(xxvii)
revision rhinoplasty
21.84
(xxviii)
other rhinoplasty
21.87
(xxix)
other septoplasty
21.88
(xxx)
other excision or destruction of lesion or tissue
								  of larynx
30.09
(xxxi)
laryngoscopy and other tracheoscopy
31.42
(xxxii)
biopsy of larynx
31.43
(xxxiii)
bronchoscopy through artificial stoma
33.21
(xxxiv)
fiber-optic bronchoscopy
33.22
(xxxv)
other bronchoscopy
33.23
(xxxvi)
biopsy of lymphatic structure
40.11
(xxxvii)
simple excision of other lymphatic structure
40.29
(xxxviii)
biopsy of bone marrow
41.31
(xxxix)
esophagoscopy through artificial stoma
42.22
(xl)
other esophagoscopy
42.23
(xli)
biopsy of esophagus
42.24
(xlii)
gastroscopy through artificial stoma
44.12
(xliii)
other gastroscopy
44.13
(xliv)
other endoscopy of small intestine
45.13
(xlv)
flexible fiberoptic colonoscopy
45.23
(xlvi)
other endoscopy of large intestine
45.24
(xlvii)
local excision of rectal lesion or tissue
48.35
(xlviii)
incision or excision of perianal tissue
49.01
(xlix)
local excision or destruction of other lesion or
								  tissue of anus
49.3
(l)
other procedures on hemorrhoids
49.49
(li)
laparoscopy
54.21
(lii)
other cystoscopy
57.32
(liii)
urethral meatotomy
58.1
(liv)
release of urethral stricture
58.5
(lv)
dilation of urethra
58.6
(lvi)
bilateral endoscopic ligation and crushing of
								  fallopian tubes
66.21
(lvii)
bilateral endoscopic ligation and division of
								  fallopian tubes
66.22
(lviii)
other bilateral endoscopic c destruction or
								  occulsion of fallopian tubes
66.29
(lix)
other cervical biopsy
67.12
(lx)
dilation and curettage for termination of
								  pregnancy
69.01
(lxi)
other dilation and curettage
69.09
(lxii)
aspiration curettage of uterus for termination of
								  pregnancy
69.51
(lxiii)
other aspiration curettage of uterus
69.59
(lxiv)
marsupialization of Bartholin's gland (cyst)
71.23
(lxv)
other bunionectomy
77.59
(lxvi)
removal of internal fixation device
78.6
(lxvii)
arthroscopy (knee)
80.26
(lxviii)
excision of lesion of tendon sheath of hand
82.21
(lxix)
excision of lesion of other soft tissue
83.39
(lxx)
other biopsy of breast
85.12
(lxxi)
local excision of lesion of breast
85.21
(lxxii)
incision w/removal of foreign body from skin and
								  subcutaneous tissue
86.05
(lxxiii)
application of other cast
93.53
(10) Nothing contained in either paragraph
					 (8) or (9) of this subdivision shall prevent any of the procedures listed in,
					 or otherwise covered by, paragraph (9) of this subdivision from being performed
					 on an outpatient basis.