Ancillary Policy for Laboratories September 23, 2010

43 Pages·2010·0.2 MB·English

STATE OF NEW YORK
DEPARTMENT OF HEALTH
Ambulatory Patient
Groups Implementation
Ancillary Policy for Laboratories
September 23, 2010
Office of Health Insurance Programs
Presentation Outline
(cid:131) Status of APG implementation in DTCs
(cid:131) Overview of APGs, with respect to ancillary (e.g., laboratory)
billing policies
(cid:131) Special payment rules and APG carve-outs
(cid:131) APG resource materials for providers
(cid:131) Question and answer period
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Speakers
Ronald Bass, Director
Bureau of Policy Development and Coverage
Division of Financial Planning and Policy
Office of Health Insurance Programs
Alan Maughan, Director
Bureau of Strategic Planning and Data Analysis
Division of Financial Planning and Policy
Office of Health Insurance Programs
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APG Implementation Status
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Office of Health Insurance Programs
Status of APG Implementation
(cid:131) APGs were implemented in hospital-based outpatient
clinics and ambulatory surgery units on December 1,
2008.
(cid:131) APGs were implemented in hospital emergency
departments on January 1, 2009.
(cid:131) APGs were approved by CMS on 6/14/2010 for free-
standing clinics and ambulatory surgery centers
retroactive to 9/1/2009.
(cid:131) Ancillary billing policy for DTCs has been delayed until
January 1, 2011.
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APG Payment
Methodology Overview
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Office of Health Insurance Programs
What are APGs?
(cid:131) APGs are a classification/reimbursement system,
developed by 3M HIS (remember the scotch tape
people?)
(cid:131) APGs are designed to detail the amount and type of
resources used in ambulatory visits.
(cid:131) APGs:
Predict the average pattern of resource use for a group of
(cid:131)
patients by combining procedures, medical visits and/or ancillary
tests that share similar characteristics and resource utilization;
Provide greater reimbursement for higher intensity services and
(cid:131)
less reimbursement for low intensity services; and
Allow more payment homogeneity for comparable services
(cid:131)
across all ambulatory care settings (e.g., outpatient department
and diagnostic and treatment centers).
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PRIMARY TYPES OF APG
S
(cid:131) SIGNIFICANT PROCEDURES: A procedure which constitutes the reason for
the visit and dominates the time and resources expended during the visit.
Examples include: excision of skin lesion, stress test, treating fractured limb.
Normally scheduled.
(cid:131) MEDICAL VISITS: A visit during which a patient receives medical treatment
(normally denoted by an E&M code), but did not have a significant procedure
performed. E&M codes are assigned to one of the 181 medical visit APGs based
on the diagnoses shown on the claim (usually the primary diagnosis).
(cid:131) ANCILLARY TESTS AND PROCEDURES: Ordered by the primary physician
to assist in patient diagnosis or treatment. Examples include: immunizations,
plain films, laboratory tests.
(cid:131) OTHER TYPES OF APGs: Drugs, DME (not used in NYS, paid through fee
schedule), Incidental to Medical Visit (always packaged), Per Diem, Inpatient-Only
(not eligible for payment), Unassigned (not eligible for payment)
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Office of Health Insurance Programs
APG PAYMENT DEFINITIONS
(cid:131) Consolidation (or Bundling)
The inclusion of payment for a related procedure into the payment for a
(cid:131)
more significant procedure provided during the same visit.
CPT codes that group to the same APG are consolidated.
(cid:131)
(cid:131) Packaging
The inclusion of payment for related medical visits or ancillary services
(cid:131)
in the payment for a significant procedure.
The majority of “Level 1 Ancillary” APGs are packaged.
(cid:131)
(i.e. pharmacotherapy, lab and radiology)
(cid:131)
Uniform Packaging List is available online at the DOH APG website.
(cid:131)
(cid:131) Discounting
A discounted payment for an additional, but unrelated, procedure
(cid:131)
provided during the same visit to acknowledge cost efficiencies.
If two CPT codes group to different APGs, 100% payment will be
(cid:131)
made for the higher cost APG, and the second procedure will be
discounted (generally at 50%).
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Examples of Laboratory Test APGs
Level of Test
Test Category APG
Complexity
Level I 390
Pathology
Level II 391
Pap smears 392
Blood and Tissue Typing 393
Level I 394
Immunology Tests
Level II 395
Level I 396
Microbiology Tests
Level II 397
Level I 398
Endocrinology Tests
Level II 399
Chemistry Basic 402
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Office of Health Insurance Programs