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APG Information Page For OASAS-Certified Outpatient Chemical Dependence Programs
APG Part 822-4 and Part 822-5 Clinical and Billing Refresher Training - Including, Part 822-5 APG Medicaid Claiming Requirements for dates of service 7/2/2012 forward as discussed in the following document titled "Attention OASAS Certified Part 822-5 Opioid Treatment Programs Revised OTP APG Claiming Rules." 
Implementation Utilization Threshold; and, APG Interim Claim Reprocessing: (Updated December 2012)
- OASAS CPT CODING CROSSWALK (Updated December 2012) OASAS has received notication 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. In most instances, there is a one for one match from the deleted CPT code to the 2013 replacement CPT code.
- Interim Claims Process has Begun: Updated Letter Explaining APG Interim Claims Processing:(Updated December 2012) The APG Interim claims processing for OASAS Certified Freestanding Part 822-4 and Part 822-5 programs has begun. Please use the above link to review the letter providing full details. Questions should be directed to the APG mailbox. APG@OASAS.ny.gov.
- Full Letter explaining Utilization Threshold and APG Interim Claim Reprocessing:
- 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.
- APG Interim Claim Reprocessing: OASAS Certified Freestanding Outpatient Clinic / Rehabilitation and Opioid Programs began APG interim claiming on July 1, 2011, and July 4, 2011, respectively. During the interim period programs were instructed to submit claims using the pre APG rate code in the header and the APG service codes at the line level. Programs were also informed that, at a future date, the interim period claims would be reprocessed to APG claims. The interim claiming period ended December 31, 2011, for Outpatient Clinic / Rehabilitation Programs and January 1, 2012, for Opioid programs.
Implementation of Ambulatory Patient Groups (APGs)
ATTENTION: January 2012 Activation of APG rate codes and reimbursement amounts in Freestanding Programs.
With the expectation that the Federal Medicaid State Plan Amendment will be approved in the near future, 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.
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 will convert to APG Medicaid Billing.
2. All programs will convert by July 2011. Hospital Dates: Part 822 clinics- Oct. 2010; Hospital Opioid Jan 3, 2011. Freestanding Programs July 2011.
3. Per note above, for dates of services after January 1, 2012 (clinics) and January 2, 2012 (opioid) Freestanding programs must submit claims using the APG rate codes. Until further notification hospital programs will continue to bill for Medicaid using the appropriate threshold rate codes and reimbursement amounts.
- General APG Background
- OASAS APG Implementation
- OASAS APG Service Categories
- The OASAS APG Steering Committee and OASAS APG Clinical Workgroup
- OASAS APG Background Documents
- OASAS APG Final Implementation Documents:
- Clinical and Medicaid Billing Manual (Updated May 2013) The May 2013 version of the manual was updated to reflect previously released information including:
- 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 (insted of H0050) for post-admission brief treatment.
- APG Interim Guidance Letters to the field, including separate APG interim billing guidance to hospitals and freestanding programs (Updated August 2011 to add previously released APG interim guidance to freestanding programs; clinic hospital interim guidance was effective October 2010; Hospital Opioid Jan 4, 2011)
- January 2012 Activation of APG rate codes and reimbursement amounts in Freestanding Programs.
- 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.
- Regulations
- Encounter Form (Updated May 2013) 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 (Updated May 2013) The May 2013 version of the manual was updated to reflect previously released information including:
- OASAS APG Training
- Questions/Contact Information
General APG Background:
The NYS Department of Health (DOH) is engaged in an overall effort to reform Medicaid reimbursement and rationalize service delivery. Part of this effort includes replacing the current Medicaid outpatient "threshold visit" methodology with the Ambulatory Patient Groups (APG) payment methodology. Generally, the APG Medicaid payment methodology provides greater reimbursement for high intensity services and relatively less reimbursement for low intensity services. This new payment methodology also allows for greater payment homogeneity for comparable services across all ambulatory care settings. By linking payments to the specific array of services rendered, APGs will make Medicaid reimbursement more rational. The new APG reimbursement methodology will replace the current reimbursement system for ambulatory care services which is a mix of outdated methodologies that have been frozen or not updated to realistically reflect the cost of providing care. These methodologies are often based on fixed dollar payments that do 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.
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OASAS APG Implementation within the OASAS-Certified Outpatient Chemical Dependence Programs: Changes Associated with Clinical Service Delivery and Medicaid Billing
From 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 new APG reimbursement methodology will replace the current 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 will: 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.
OASAS APG Service Categories:
OASAS worked with the Department of Health, the Office of Mental Health, the Office of Mental Retardation and Developmental Disabilities and providers to create APG billing categories that accurately reflect the scope of clinic services. APGs provide uniformity in Medicaid billing for behavioral health entities across disabilities and were also created to maintain service delivery patterns unique to each disability. Specifically, under APGs the outpatient chemical dependence service array was disaggregated from the former large categories of: assessment, individual and group services and the previous methadone week into more discrete clinically related service delivery and billing categories. The new categories capture the major behavioral health service groupings that are delivered in the OASAS certified outpatient clinics and include:
The APG Steering Committee and APG Clinical Workgroups:
OASAS would like to acknowledge and thank the providers and provider representatives who have dedicated their time and expertise to assist OASAS in the development and implementation of APGs within the OASAS outpatient system.
- APG Steering Committee: The APG Steering Committee members advised OASAS on steering the APG development and implementation process; provided input / advise on policy /fiscal issues; and, reported back to their own membership on APG implementation.
- APG Clinical Workgroup:The APG Clinical Workgroup provided input and advisement on: development of the APG service categories; and, the associated clinical and service delivery parameters.
OASAS APG Background Documents:
The OASAS APG policy and pricing process was developed incrementally. Parties interested in viewing the progression of background power points and frequently asked questions may choose to view the two part background series below. Parties interested in skipping the background components are advised to go directly to the final implementation documents listed below.
Background Power Points:
- Part One:
- Part Two:
Introduction to APGs - Frequently Asked Questions: The questions in this document respond to preliminary / background questions associated with: APG Pricing; Systems Issues; APG service Categories; and other miscellaneous questions. NOTE: The FAQs in this document are for historical purposes only and may have changed over time. To ensure understanding of final policy, programs must read the online APG Clinical and Medicaid Billing Manual and / or review the online APG FAQS.
- OASAS Final Implementation Documents:
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.
- Final Clinical Service / Medicaid Billing Manual: Combined Ambulatory Patient Groups (APGs) Policy and Medicaid Billing Guidance for OASAS-Certified Outpatient Chemical Dependence Programs. Effective January 2012 this manual has been updated to reflect additional clarification and policy updates.
- Interim Guidance Billing Letters to the field
- October 2010 APG Interim Billing Guidance for Hospitals
October 4, 2010 APG Date for OASAS Certified Hospital Based Opioid Treatment Programs - DELAYED TO JANUARY 3, 2011 - This is to alert the field, that as indicated above the anticipated October 4, 2010 APG implementation date for OASAS certified hospital based opioid treatment programs will be delayed from October 4, 2010 to at least November 8, 2010. JANUARY 3, 2011. Prior to January 3 Hospitals should review the Interim Guidance letter to the field regarding interim APG claiming for hospital based programs. Prior to January 3rd hospital Opioid programs must continue to use the existing weekly threshold rate code.
- October 1, 2010 APG Date for OASAS Certified Hospital Based Outpatient Clinic Programs - REMAINS -
The October 1, 2010 APG date for OASAS certified hospital based outpatient clinic programs remains and programs should follow the claiming instructions as indicated in the above "Interim Guidance Letter to the Field".
- July 1, 2011 APG Interim Billing Guidance for Freestanding Programs. (Updated August 2011 to add previously released APG freestanding program guidance letter )
Effective July 1, 2011 all OASAS certified Part 822 programs must deliver and document services for all patients (regardless of payor source) in accordance with the new Part 822 regulations. OASAS has not however, received Federal approval to utilize the Freestanding APG rate codes or reimbursement methodology and thus are in the interim billing period. Please see the attached interim guidance document. Until Federal Approval is received all Freestanding Outpatient Clinic and Opiod programs must follow the claiming instructions in the July 1, 2011 APG Interim Billing Guidance for Freestanding 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.
- Final APG Prices and the Phase In: This information is updated and effective as of November 2011.
- APG Price, Service Weight and Coding: Will be posted when final.
- 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 non-hospital and hospital based programs.
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
Percent of Current Threshold Legacy Payment
APG Payment
Phase 1: July 1, 2011 - June 30, 2012
75%25%
of the full APG PaymentPhase 2: July 1, 2012 - June 30, 2013 50%50%
of the full APG PaymentPhase 3: July 1, 2013 - December 31, 2013 25%75%
of the Full APG paymentPhase 4: January 1, 2014 0100% o
of the full APG Payment
NOTE ONE: The Medicaid billing conversion from Medicaid threshold rate codes to APG codes will not be phased. 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, Service Weight and Coding: Will be posted when final.
- 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.
APG Revenue Calculator Instructions
(Updated February 2011)
Freestanding Program APG Revenue Calculator
(Updated Oct 2012)
Hospital-Based Program APG Revenue Calculator (Updated Oct 2012)
Summary of APG payments in OASAS freestanding programs effective for dates of service 7/1/11-6/31/12. Any changes to OASAS APG payments either via base rate or weight adjustments would be reflected below and in the revenue calculator. The payments reflected in the table immediately below are applicable once APGs have completed the phase in process. The phase in process is described in the: table titled "Base Rate Blend Dates / Schedules"; and, in the OASAS APG clinical and billing guidance manual.
- Final APG OASAS Regulations: The OASAS APG regulations have been published for public comment.
- OASAS Part 822. The proposed regulation includes revisions to Part 822 Outpatient, APG Implementation and Incorporation of Part 828 Opioid Treatment Services
- OASAS Part 841 The proposed regulation is for the purpose of establishing standards for reimbursement and participation in the Medical Assistance Program, as authorized by title 11 of article 5 of the Social Services Law, for services provided by chemical dependence providers certified or co-certified by the Office of Alcoholism and Substance Abuse Services. This Part does not apply to [facilities certified by the Office of Alcoholism and Substance Abuse Services and licensed pursuant to Article 28 of the Public Health Law] hospital based programs.
- 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. (Updated July 2011)
- 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
- 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 (Added May 2011)
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.
Phase Hospital Programs
Phase DatesFreestanding Programs
Phase DatesReimbursement 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 programs75 % legacy
25 % APG2 January 1 - December 31, 2010
October 1, 2010 APG Start date for OASAS certified hospital based outpatient clinic programsJuly 1, 2012 - June 30, 2013 50 % legacy
50 % APG3 January 1 - December 31, 2011
January 3, 2011 APG Start Date for OASAS certified hospital based Opioid ProgramsJuly 1, 2013 - December 31, 2013 25 % Legacy
75% APG4 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:
This may only occur if the physician provides a service typically provided by clinical staff and applies only to admission assessment; individual counseling or group counseling services.
https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician_Billing_Guidelines.pdf
- October 2010 APG Interim Billing Guidance for Hospitals
- APG Training - OASAS staff provided an APG implementation overview. The overview provided an introduction to APGs in the OASAS outpatient system; the associated APG OASAS services map; and, APG Medicaid billing rules the training provided an overview of the OASAS online APG revenue calculator; and used the following power point.
OASAS staff also delivered 11 regional face to face trainings during the summer of 2010. Questions you may have on OASAS APG implementation may be directed as follows:
Question Topic AreaInitial Contact PointAPG Clinical and Medicaid Billing Questions: APG Medicaid Pricing Questions: Base, Weight, Phase In The APG OASAS Provider Revenue Calculator APG OASAS Specific Medicaid Billing Questions General Medicaid Billing Questions Questions Grouper Software/Pricer Product Support
3M HIS Sales
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. |
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Screening and Brief Intervention and Brief Treatment |
Individual Counseling Brief |
Medication Administration and Observation |
Individual Counseling Normative |
Medication Management Routine |
Group Counseling |
Medication Management Complex |
Collateral Visit |
Assessment Brief |
Complex Care Coordination |
Assessment Normative |
Peer Counseling |
Assessment Extended |
Outreach |
Intensive Outpatient |
Outpatient Rehabilitation |