APG Information Page For OASAS-Certified Outpatient Chemical Dependence Programs
APG Updates and News
Peer Services rate increase: As of July 1, 2015 the Peer Support Services (H0038) payment rate will be increased to $13.05/Downstate and $11.15/Upstate for a 15 minute duration. Peer Support is a procedure based weight that recognizes units. Providers will no longer be restricted to the previous 30 minute minimum, and limit of 5 Peer services per episode of care. The code does have a maximum of four units per visit date, which means that providers will not get paid for more than an hour. With the focus on Recovery Oriented Care the increase in this rate and frequency will give flexibility to in providing support for the individual needs/goals within Outpatient Chemical Dependency treatment. For further information on Peer Services billing please review the OASAS Medicaid APG Billing and Clinical Guidance Document.
- Schedule for Implementation of Hospital Based APG Reimbursement Methodology -This notice is to announce the schedule for implementation. This SPA approves the use of the APG reimbursement methodology for Outpatient Clinics effective October 1, 2010, and for OTPs effective January 3, 2011.
- Post Interim Guidelines for Buprenorphine billing in Opioid Treatment Programs - With SPA approval for APG billing in Hospital-based OTPs, new procedures and coding are in place for buprenorphine billing.
- Opioid Treatment Programs Temporary Transfers and Medicaid Billing Guidelines - This is policy guidance to the field regarding how to facilitate temporary transfers and associated Medicaid Billing Guidance.
- Billing code for former Medication Management Routine - The Medication Management code M0064, “visit for Drug Monitoring,” was deactivated effective 12/31/2014. Effective for Dates of Service 01/01/2015 forward, use E&M codes 99201-99215, for NEW PATIENTS, and E&M codes 99211-99205 for EXISTING PATIENTS. The E&M code selected for billing is based on the complexity of the client. The reimbursement will pivot off the diagnosis code shown on the claim.
- Buprenorphine Rate Codes - Recently, OASAS OTP providers were notified that APG billing, using the prior dosage based weekly Buprenorphine rate codes (2531-2534), would be available for Medicaid reimbursement retroactive to dates of service beginning January 1, 2014. Previously, it was announced that the rate codes used prior to the conversion to APGs would end effective October 1, 2014. The end date for these rate codes has been extended to January 5, 2015 to allow providers enough time to adapt their billing systems to the change. Beginning January 5, 2015, rate Codes 2531-2534 will no longer be available.
- How to Bill for Services When Provided by a Physician - for all Freestanding and Hospital-Based OASAS-certified Chemical Dependence Outpatient Clinics, Chemical Dependence Outpatient Rehabilitation Programs, Outpatient Youth Programs and Opioid Treatment Providers. To simplify the billing for the physician add-on reimbursement, OASAS is implementing the use of a modifier replacing the separate Professional claim (837P) that was previously used to obtain the enhanced physician add-on reimbursement
- Clinical and Billing Guidance for Buprenorphine Reimbursement using APGs - Programs will be able to bill for services through APG methodology for services and medication costs retroactive to January 2014. Programs will submit a visit based service payment claim using the four digit weekly OTP APG rate code (1564) in the claim header.
- Weight Change for CPT Code 90882 - Effective July 1, 2014 the weight for CPT code 90882 - Complex Care Coordination will be .0965 per unit. For each occurrence of Complex Care Coordination being provided to a client adhering to the requirements of the APG Clinical and Billing Guidance manual, providers will need to bill three (3) units on their claim to receive proper reimbursement.
- Freestanding Chemical Dependence Outpatient Clinics, Chemical Dependence Outpatient Rehabilitation and Outpatient Youth Programs - Effective January 1, 2014 APG reimbursement will be fully implemented in Freestanding Chemical Dependence clinics, Chemical Dependence Outpatient Rehabilitation and Outpatient Youth programs. This is the conclusion of the multi-year phase-in from the blended threshold/legacy APG reimbursement to full APG reimbursement. Effective January 1, 2014 reimbursement for services provided will be calculated using only the APG reimbursement methodology.
- Freestanding Opioid Treatment Providers - Effective January 6, 2014 APG reimbursement will be fully implemented in Freestanding Opioid Treatment Programs. This is the conclusion of the multi-year phase-in from the blended threshold/legacy APG reimbursement methodology to full APG reimbursement. Effective January 6, 2014 reimbursement for services provided will be calculated using only the APG reimbursement methodology. Therefore, effective January 6, 2014 the legacy reimbursement portion is phased out, meaning the rate code 1671 should no longer be used.
- OASAS CPT CODING CROSSWALK - OASAS received notification that the American Medical Association (AMA) is making significant changes to the psychiatric CPT codes effective January 1, 2013. As such programs should review the OASAS CPT coding crosswalk which illustrates the OASAS Service Category, the CPT code that is being deleted, the HCPCS code that is available for billing and the new/replacement 2013 CPT code.Â In most instances, there is a one for one match from the deleted CPT code to the 2013 replacement CPT code.
- Utilization Threshold: To avoid an across-the-board Medicaid cut in 2011-12, OASAS (and OMH) implemented a new Utilization Threshold (UT) program for outpatient clinic visits pursuant to Medicaid Redesign Team Proposal #26. Under this proposal, mental hygiene clinic Medicaid payments will be automatically reduced according to patient-specific utilization standards or thresholds. For patients that exceed the UT thresholds, claims submitted by the provider will be reduced by specific percentages. The UT program became effective April 1, 2011.
Ambulatory Patient Groups (APGs)
January 2012 Activation of APG rate codes and reimbursement amounts in Freestanding Programs.
OASAS announced to the field that, in freestanding programs only, utilization of Ambulatory patient Group (APGs) rate codes and reimbursement methodology began for outpatient clinics and rehabilitation programs on January 1, 2012, and on January 2, 2012, for opioid programs. For dates of service after these dates, freestanding programs must use the correct four digit APG rate code for their peer group when submitting Medicaid claims and may not use the pre-APG threshold visit or OTP weekly visit rate codes. Questions regarding this announcement should be directed to APG@oasas.ny.gov.
NOTE: Certified Outpatient Chemical Dependence Programs include
Chemical Dependence Medically Supervised Outpatient Clinics and Rehabilitation Programs; Outpatient Opiate Treatment; and Outpatient Chemical Dependency for Youth Programs.
1. Providers that operate these OASAS Certified Outpatient Chemical Dependence Programs have converted to APG Medicaid Billing.
2. All programs converted by July 2011. Hospital Dates: Part 822 clinics- Oct. 2010; Hospital Opioid Jan 3, 2011. Freestanding Programs July 2011.
3. For dates of services after January 1, 2012 (clinics) and January 2, 2012 (opioid) Freestanding programs must submit claims using their APG rate codes. Until further notification, hospital programs continue to bill for Medicaid using the appropriate threshold rate codes and reimbursement amounts.
- General APG Background
- OASAS APG Implementation
- OASAS APG Service Categories
- OASAS APG Implementation Documents:
- Clinical and Medicaid Billing Manual
- American Medical Association (AMA) psychiatric CPT codes that went into effect in Jan 2013;
- Use of the KP modifier coding for OTP claiming.
- Use of H0004 (instead of H0050) for post-admission Brief Treatment.
- January 2012 Activation of APG rate codes and reimbursement amounts in Freestanding Programs
- Regional APG Base Rates Chemical dependence and opioid treatment programs APG peer group base rates.
- APG Medicaid Revenue Calculator (Updated October 2012 ) The Revenue Calculators have been updated to take into consideration the 1st day enhanced payment for Medication Administration, weights for certain CPT/HCPSC codes have been updated to reflect changes that have been made, and the weights for physical health have been updated.
- Medicaid APG Rate Per Service Table - explanatory table that reflects full APG rates for freestanding clinic and opioid programs and summary of hospital and freestanding program reimbursement phase schedule.
- Encounter Form The May 2013 version of the encounter form was updated to reflect American Medical Association (AMA) psychiatric CPT codes that went into effect in Jan 2013; and, use of H0004 (replaces H0050) for post-admission brief treatment.
- Vendor Training Video and Power Point (Added November 2010)
- Readiness Checklist (Added November 2010)
- Medicaid Billing Self Assessment Tool (Added May 2011)
- Clinical and Medicaid Billing Manual (revised 6/2015)
- OASAS APG Training
- Questions/Contact Information
The APG reimbursement methodology will replace the outdated reimbursement system for ambulatory care services which was a mix of methodologies that have been frozen or not updated to realistically reflect the cost of providing care. The outdated methodologies were often based on fixed dollar payments that did not vary by severity of illness or complexity of procedure. These antiquated reimbursement methodologies thwart the appropriate migration of services from costly acute care settings to less costly primary and preventive care settings. For information on the overall Department of Health APG initiative please see the New York State Department of Health website once there, click on the "A-Z Index Tab", and then go to the "Ambulatory Patient Group" bullet.
OASAS APG Implementation within the OASAS-Certified Outpatient Chemical Dependence Programs: Changes Associated with Clinical Service Delivery and Medicaid BillingFrom OASAS' perspective implementing Ambulatory Patient Groups (APGs) for behavioral health services is a key component of New York state’s overall effort to reform Medicaid reimbursement and rationalize service delivery.
- Clinical Service Delivery: Clinically, for the addiction field, the implementation of APGs is an integral part of the evolutionary move by the addictions field towards one outpatient system of care. APGs support a range of medically necessary clinic services for patients based on the evidence of what works to promote recovery from chemical dependency.
- Medicaid Billing: From a Medicaid reimbursement perspective the APG reimbursement methodology replaced the threshold visit reimbursement system for clinic services. The APG payment methodology pays differential amounts for ambulatory care services based on the resources required for each service provided during a patient visit. In addition, APGs support discrete Medicaid reimbursement for some chemical dependence services that were not previously billable; and, allow for some services that are integral to the treatment of patients in chemical dependency treatment such as mental and physical health services.
During and after the transition, providers will generally need to submit one claim for each visit capturing all procedures. An additional claim will need to be submitted for each service billed off the physician fee schedule. The Medicaid system will automatically attach each provider's previous Medicaid threshold payment to the APG (procedure) service paid. The threshold payment will decline each year as the APG payment increases.
APG Service Delivery Category
For a complete explanation of the APG Service Categories and associated Medicaid billing changes see the Combined Ambulatory Patient Groups (APGS) Policy and Medicaid Billing Guidance for OASAS Certified Outpatient Chemical Dependence Programs.
Screening, Brief Intervention and Brief Treatment
Individual Counseling Brief
Medication Administration and Observation
Individual Counseling Normative
Medication Management Routine
Medication Management Complex
Complex Care Coordination
Addiction Medication Induction/Withdrawal
Intensive Outpatient Service
For assistance or concerns regarding accessibility of these documents, contact the OASAS Communications Bureau at 518-457-8299 or via e-mail at Communications@oasas.ny.gov.
- Clinical Service / Medicaid Billing Manual: (revised 05/01/2015) Combined Ambulatory Patient Groups (APGs) Policy and Medicaid Billing Guidance for OASAS-Certified Outpatient Chemical Dependence Programs.
- January 2012 APG Rate Code and Reimbursement Amounts Activated for Freestanding Programs.
OASAS recently announced to the field that in freestanding programs only, utilization of Ambulatory patient Group (APG) rate codes and reimbursement methodology is scheduled to begin for outpatient clinics and rehabilitation programs on January 1, 2012 and on January 2, 2012 for opioid programs. For dates of service after these dates, freestanding programs must use the correct four digit APG rate code for their peer group when submitting Medicaid claims and may not use the pre-APG threshold visit or OTP weekly visit rate codes. The providers were sent a letter explaining, in detail, the process for using APG rate codes for claims and for reprocessing previously submitted interim period claims. Questions regarding this announcement should be directed to APG@oasas.ny.gov.
- APG Prices and the Phase In:
- APG Price Phase In:
- APG reimbursement will be calculated on a blended basis. Reimbursement for each individual visit will be based on a percentage of the full amount that the APG methodology would calculate for the visit (based on coded procedures and diagnoses) and plus a percentage of the provider - specific Medicaid payment amount called the Legacy amount.
- The Legacy amount will be based on a provider’s pre-existing per visit Medicaid reimbursement amount. The table below outlines the blend phases for Freestanding programs, only.
Freestanding Programs will enter into APGs in July 2011 using the schedules listed below.
NOTE: Freestanding Opioid programs will begin on Monday July 4, 2011
% of Current Threshold/ Legacy Payment
Phase 1: July 1, 2011 - June 30, 2012
of the full APG Payment
Phase 2: July 1, 2012 - June 30, 201350%50%
of the full APG Payment
Phase 3: July 1, 2013 - December 31, 201325%75%
of the Full APG payment
Phase 4: January 1, 20140100%
of the full APG Payment
NOTE ONE: Upon APG implementation, the Medicaid claiming system will no longer accept the previous threshold rate codes. Medicaid claims for dates of service after the APG activation date must be submitted to Medicaid using APG coding.
- APG Price Phase In:
- The APG OASAS Provider Revenue Calculator:
- Revenue Calculator:OASAS developed the APG Medicaid Revenue Calculator.
The calculator simulates Medicaid revenues projections associated with APG pricing. OASAS Certified outpatient programs may use the tool to continuously monitor and update their projected APG Medicaid revenues. Calculator have the base rates for the respective programs / peer groups; and, the application of the phased payments.
- Summary of APG payments in OASAS Freestanding programs.
- APG OASAS Regulations:
- Sample Encounter Form: In response to provider community request OASAS developed a sample encounter form to assist providers in their APG implementation efforts. Providers are not required to use this form.
- Vendor Training: Providers and their in-house or contracted billing staff or vendors are encouraged to view the PowerPoint provided below.
- Vendor Power Point Printed version of the power point.
- Vendor Power Point Printed version of the power point.
- Readiness Checklist: In response to provider community request OASAS developed a suggested readiness checklist to assist providers in their APG implementation efforts. Providers are not required to use this checklist.
- Medicaid Self Assessment: This is a voluntary tool that will support programs ability to conduct periodic self - assessment of their Medicaid patient's case record documentation and claiming for adherence to OASAS case record compliance standards and Medicaid billing requirements. Programs are strongly encouraged to complete the self assessment form as a routine part of program operations. This tool is for dates of service after July 1, 2011.
The payments reflected in the table below are applicable once APGs have completed the phase in process. Any changes to OASAS APG payments either via base rate or weight adjustments would be reflected below and in the revenue calculator. The phase in process is described in the table titled "OASAS Freestanding APG Blend Implementation Schedule"; and, in the OASAS APG Clinical and Billing Guidance manual.
Base Rate Blend Dates / Schedules
APG reimbursement programs will be phased in over time (see schedules below).
The phase in means that reimbursement for services delivered on each individual visit date will be based on a percentage of the full amount (see rows above) that the APG methodology would calculate for the delivered service (based on coded procedures and diagnoses) plus a single accommodation that reflects a percentage of the provider specific Medicaid payment amount called the Legacy amount.
Programs are instructed to utilize the APG revenue calculators to simulate Medicaid revenues projections associated with APG pricing / the phase in.
|Reimbursement Blend Percentages
(Legacy %-APG %)
|1||Not Applicable||July 1, 2011 - June 30, 2012
Monday, July 4, 2011 APG Start date for OASAS Certified Freestanding Opioid programs
|2||January 1 - December 31, 2010
October 1, 2010 APG Start date for OASAS certified hospital based outpatient clinic programs
|July 1, 2012 - June 30, 2013||50% legacy
|3||January 1 - December 31, 2011
January 3, 2011 APG Start Date for OASAS certified hospital based Opioid Programs
|July 1, 2013 - December 31, 2013||25% Legacy
|4||January 1, 2012||January 1, 2014||100% APG|
|Physician Fee Schedule:|
|A physician add-on is available when the physician provides the entire: assessment; individual or group counseling service on-site at the OASAS certified Part 822-4 or Part 822-5 location. In such instances s/he can bill a separate single Physician Fee claim to secure an additional $56 "add-on" to account for the additional cost for the service. The add-on is only available for assessment; individual; or; group counseling service.
For claiming instructions go to:
APG Part 822-4 and 822-5 Clinical and Billing Refresher Training for APG Medicaid Claiming requirements including Opioid Treatment Programs revised OTP APG Claiming rules.
Question Topic Area
Initial Contact Point
|APG Clinical and Medicaid Billing Questions:|
|APG Medicaid Pricing Questions: Base, Weight, Phase In||
OASAS: Bureau of Health Care Financing
|The APG OASAS Provider Revenue Calculator|
|APG OASAS Specific Medicaid Billing Questions|
|General Medicaid Billing Questions||
Computer Sciences Corporation
| Questions Grouper Software/Pricer
3M HIS Sales
3-M Health Information Systems, Inc.