New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter C - Medical Treatment and Care › Part 329 - Medical, Outpatient And Ambulatory Surgery Services Fee Schedules › Subpart 329-2 - Ambulatory Surgery Services Fee Schedule › Section 329-2.2 - Definitions: Ambulatory Patient Group

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Subpart, the following definitions shall
						apply:
(a) Ambulatory Patient Group
					 (''APG'') shall mean a defined group of outpatient procedures, encounters or
					 ancillary services, as specifically identified and published by the Department
					 of Health, which reflect similar patient characteristics and resource
					 utilization and which incorporate the use of ICD-10-CM diagnosis codes and
					 CPT-4 and HCPCS procedure codes, as defined below;
(b) Allowed APG weight shall mean the
					 relative resource utilization for a given APG after adjusting for
					 consolidation, packaging, and discounting.
(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.
(d) Workers' Compensation specific base rates
					 shall mean the numeric value that shall be multiplied by the allowed APG weight
					 for a given APG, or by the final APG relative weight to determine the total
					 allowable Workers' Compensation operating payment for a visit.
(e) Consolidation, also known as
					 ''bundling'', shall mean the process for determining if a single payment amount
					 is appropriate in those circumstances when a patient receives multiple APG
					 procedures during a single patient visit.
(f) Current Procedural Terminology, fourth
					 edition (CPT-4) is the systematic listing and coding of procedures and services
					 provided by physicians or other related health care providers. It is a subset
					 of the Healthcare Common Procedure Coding System (HCPCS). The CPT-4 and HCPCS
					 are maintained by the American Medical Association and the federal Centers for
					 Medicare and Medicaid Services and are updated annually.
(g) Discounting shall mean the reduction in
					 APG payment that results when additional procedures do not consolidate.
					 Additional occurrences of the same ancillary APG within a single visit or
					 episode will also discount.
(h) APG
					 Software System shall mean the New York State-specific version of the APG
					 computer software developed and published by Minnesota Mining and Manufacturing
					 Corporation (3M) to process CPT-4 and ICD-10 code information in order to
					 assign patient visits to the appropriate APG category or categories and apply
					 appropriate bundling, packag- ing and discounting to assign the appropriate
					 final APG weight and associated reimbursement.
(i) Final APG Weight shall mean the allowed
					 APG weight for a given visit as expressed in the applicable APG software, and
					 as adjusted by all applicable consolidation, packaging and discounting and
					 other applicable adjustments.
(j)
					 International Classification of Diseases, 10th Revision (ICD-10) is a
					 comprehensive coding system maintained by the federal Centers for Medicare and
					 Medicaid Services in the US Department of Health and Human Services. It is
					 maintained for the purpose of providing a standardized, universal coding system
					 to identify and describe patient diagnoses, symptoms, complaints, conditions
					 and/or causes of injury or illness. It is updated annually.
(k) Packaging shall mean those circumstances
					 in which payment for routine ancillary services or drugs shall be deemed as
					 included in the applicable APG payment for a related significant procedure or
					 medical visit. Medical visits also package with significant procedures, unless
					 specifically excepted herein.
(l)
					 Significant procedure APG shall mean an APG incorporating a medical procedure
					 that constitutes the primary reason for the visit in terms of time and
					 resources expended.
(m) Medical
					 visit APG shall mean an APG representing a visit during which a patient
					 received medical treatment, but did not have a significant procedure
					 performed.
(n) Visit shall mean a
					 unit of service consisting of all the APG services performed for a patient that
					 are coded on the same claim and share a common date of service.
(o) Peer Group shall mean a group of
					 providers that share a common APG Workers' Compensation specific base rate.
					 Peer groups may be established based on facility licensure, geographic region,
					 types of services provided or categories of patients.
(p) Ancillary services APGs shall mean those
					 APGs designated by the Department of Health as reflecting those tests and
					 procedures ordered by physicians to assist in patient diagnosis and/or
					 treatment.