Section 86-8.10 - Exclusions from payment

Section 86-8.10 Exclusions from payment
Payments for the following shall be excluded from rates set pursuant to this Subpart:

(a) Drugs and other pharmaceutical products and implantable family planning devices for which separate and distinct outpatient billing and payment were authorized by the Department as of December 31, 2007, and as set forth by the Department in written billing instructions issued to providers subject to this Subpart, and as may be subsequently modified by the Department, HIV counseling and testing visits, post-test HIV counseling visits (positive results), HIV counseling visit (no testing), day health care service (HIV), TB/directly observed therapy -- downstate levels 1 and 2, TB/directly observed therapy -- upstate levels 1 and 2, AIDS clinic therapeutic visits in general hospital outpatient clinics, child rehabilitation services provided under rate code 2887 in general hospital outpatient clinics, and Medicaid obstetrical and maternity services (MOMS) provided under rate code 1604.

(b) Visits solely for the purpose of receiving ordered ambulatory services.

(c) Visits solely for the purpose of receiving pharmacy services.

(d) Visits solely for the purpose of receiving education or training services, except with regard to services authorized pursuant to clause (A) of subparagraph (ii) of paragraph (f) of subdivision 2-a of section 2807 of the Public Health Law.

(e) Visits solely for the purpose of receiving services from licensed social workers, except with regard to psychotherapy services provided by Federally Qualified Health Centers or Rural Health Centers subject to reimbursement pursuant to this Subpart, or as authorized pursuant to clauses (C) and (D) of subparagraph (ii) of paragraph (f) of subdivision 2-a of section 2807 of the Public Health Law.

(f) Visits solely for the purpose of receiving group services, except with regard to clinical group psychotherapy services provided by Federally Qualified Health Centers or Rural Health Centers subject to reimbursement pursuant to this Subpart and provided, however, that reimbursement for such group services shall be determined in accordance with paragraph (h) of section 86-4.9 of this Title.

(g) Offsite services, defined as medical services provided by a facility’s outpatient staff at locations other than those operated by and under the facility’s licensure under Article 28 of the Public Health Law, or visits related to the provision of such offsite services, except with regard to offsite services provided by Federally Qualified Health Centers or Rural Health Centers and provided, however, that reimbursement for such offsite services shall be determined in accordance with paragraph (i) of section 86-4.9 of this Title.

(h) The following APGs shall not be eligible for reimbursement pursuant to this Subpart:

065 RESPIRATORY THERAPY
066 PULMONARY REHABILITATION
117 HOME INFUSION
190 ARTIFICIAL FERTILIZATION
311 FULL DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE
313 HALF DAY PARTIAL HOSPITALIZATION FOR SUBSTANCE ABUSE
314 HALF DAY PARTIAL HOSPITALIZATION FOR MENTAL ILLNESS
319 ACTIVITY THERAPY
371 ORTHODONTICS
430 CLASS I CHEMOTHERAPY DRUGS
431 CLASS II CHEMOTHERAPY DRUGS
432 CLASS III CHEMOTHERAPY DRUGS
433 CLASS IV CHEMOTHERAPY DRUGS
434 CLASS V CHEMOTHERAPY DRUGS
441 CLASS VI CHEMOTHERAPY DRUGS
443 CLASS VII CHEMOTHERAPY DRUGS
452 DIABETES SUPPLIES
453 MOTORIZED WHEELCHAIR
454 TPN FORMULAE
456 MOTORIZED WHEELCHAIR ACCESSORIES
465 CLASS XIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
999 UNASSIGNED

(i) The following APGs shall not be eligible for reimbursement pursuant to this Subpart when they are presented as the only APGs applicable to a patient visit or when the only other APGs presented with them are one or more of the APGs listed in subdivision (h) of this section:

281 MAGNETIC RESONANCE ANGIOGRAPHY – HEAD AND/OR NECK
282 MAGNETIC RESONANCE ANGIOGRAPHY – CHEST
283 MAGNETIC RESONANCE ANGIOGRAPHY – OTHER SITES
284 MYELOGRAPHY
285 MISCELLANEOUS RADIOLOGICAL PROCEDURES WITH CONTRAST
286 MAMMOGRAPHY
287 DIGESTIVE RADIOLOGY
288 DIAGNOSTIC ULTRASOUND EXCEPT OBSTETRICAL AND VASCULAR OF LOWER EXTREMITIES
289 VASCULAR DIAGNOSTIC ULTRASOUND OF LOWER EXTREMITIES
290 PET SCANS
291 BONE DENSITOMETRY
292 MRI – ABDOMEN
293 MRI – JOINTS
294 MRI – BACK
295 MRI – CHEST
296 MRI – OTHER
297 MRI - BRAIN
298 CAT SCAN BACK
299 CAT SCAN - BRAIN
300 CAT SCAN - ABDOMEN
301 CAT SCAN - OTHER
302 ANGIOGRAPHY, OTHER
303 ANGIOGRAPHY, CEREBRAL
330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE
331 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE
332 LEVEL III DIAGNOSTIC NUCLEAR MEDICINE
373 LEVEL I DENTAL FILM
374 LEVEL II DENTAL FILM
375 DENTAL ANESTHESIA
380 ANESTHESIA
390 LEVEL I PATHOLOGY
391 LEVEL II PATHOLOGY
392 PAP SMEARS
393 BLOOD AND TISSUE TYPING
394 LEVEL I IMMUNOLOGY TESTS
395 LEVEL II IMMUNOLOGY TESTS
396 LEVEL I MICROBIOLOGY TESTS
397 LEVEL II MICROBIOLOGY TESTS
398 LEVEL I ENDOCRINOLOGY TESTS
399 LEVEL II ENDOCRINOLOGY TESTS
400 LEVEL I CHEMISTRY TESTS
401 LEVEL II CHEMISTRY TESTS
402 BASIC CHEMISTRY TESTS
403 ORGAN OR DISEASE ORIENTED PANELS
404 TOXICOLOGY TESTS
405 THERAPEUTIC DRUG MONITORING
406 LEVEL I CLOTTING TESTS
407 LEVEL II CLOTTING TESTS
408 LEVEL I HEMATOLOGY TESTS
409 LEVEL II HEMATOLOGY TESTS
410 URINALYSIS
411 BLOOD AND URINE DIPSTICK TESTS
413 CARDIOGRAM
435 CLASS I PHARMACOTHERAPY
436 CLASS II PHARMACOTHERAPY
437 CLASS III PHARMACOTHERAPY
438 CLASS IV PHARMACOTHERAPY
439 CLASS V PHARMACOTHERAPY
440 CLASS VI PHARMACOTHERAPY
444 CLASS VII PHARMACOTHERAPY
448 AFTER HOURS SERVICES
455 IMPLANTED TISSUE OF ANY TYPE
457 VENIPUNCTURE
460 CLASS VIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
461 CLASS IX COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
462 CLASS X COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
463 CLASS XI COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
464 CLASS XII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY
470 OBSTETRICAL ULTRASOUND
471 PLAIN FILM
472 ULTRASOUND GUIDANCE
473 CT GUIDANCE
490 INCIDENTAL TO MEDICAL, SIGNIFICANT PROCEDURE OR THERAPY VISIT

Effective Date: 
Wednesday, March 14, 2012
Doc Status: 
Complete