New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-8 - Outpatient Services: Ambulatory Patient Group › Section 86-8.2 - Definitions

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,
					 which reflect similar patient characteristics and resource utilization and
					 which incorporate the use of ICD-9-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) 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 Medicaid 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-9 code information in order to assign
					 patient visits to the appropriate APG category or categories and apply
					 appropriate bundling, packaging 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, 9th Revision (ICD-9) 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 in this regulation.
(l) the downstate region shall consist of the
					 five counties comprising New York City, and the counties of Nassau, Suffolk,
					 Westchester, Rockland, orange, Putnam, and Dutchess.
(m) the upstate region shall consist of all
					 counties in the State other than those counties included in the downstate
					 region.
(n) 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.
(o) 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.
(p) 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.
(1) Episode shall mean a unit of service
					 consisting of all services on a claim, regardless of the coded dates of
					 service. Under episode billing, an episode shall consist of all medical visits
					 and/or procedures that are provided by a clinic to a patient on a single date
					 of service plus any associated non-carved-out ancillaries, regardless of the
					 date of service of those ancillaries. for emergency departments, the
					 significant procedures and/or medical visits comprising the non-carved-out
					 ancillary services portion of an episode need not be on a single date of
					 services and may instead be on consecutive dates of service. Multiple episodes
					 shall not be coded on the same claim.
(2) the calculation of the APG payment by the
					 APG software may be either visit-based or episode-based depending on the rate
					 code used to access the APG software logic. References to "visits" in this
					 Subpart shall be deemed to refer also to "episodes" for rate-setting
					 purposes.