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Title: Section 86-8.2 - Definitions

Effective Date


Section 86-8.2 Definitions

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.

(q) Peer Group shall mean a group of providers that share a common APG base rate. Peer groups may be established based on facility licensure, geographic region, types of services provided or categories of patients.

(r) Repealed.

(s) Ancillary services APGs shall mean those APGs designated by the Department as reflecting those tests and procedures ordered by physicians to assist in patient diagnosis and/or treatment.

(t) Case mix index shall mean the actual or estimated average final APG weight for a defined group of APG visits.

(u) No blend APG shall mean an APG that has its entire payment calculated under the APG reimbursement methodology without regard to the historical average operating payment per visit for the provider.

(v) MR/DD/TBI peer group shall mean a patient-specific peer group consisting of persons appropriately designated in the Medicaid billing system with mental retardation ("MR"), developmental disabilties ("DD") or traumatic brain injuries ("TBI").


VOLUME A-2 (Title 10)