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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." PDF Document

APG Updates and News

  • New Notice to field: 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
  • New Notice to field: Clinical and Billing Guidance for Buprenorphine Reimbursement using APGs PDF Document 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.
  • Notification: Weight Change for CPT Code 90882NewEffective 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 PDF DocumentEffective 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 PDF Document 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. 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.

  1. General APG Background
  2. OASAS APG Implementation
  3. OASAS APG Service Categories
  4. OASAS APG Implementation Documents:

  5. OASAS APG Training
  6. Questions/Contact Information

  1. 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 Medicaid outpatient "threshold visit" methodology with the Ambulatory Patient Groups (APGs) payment methodology. Generally, the APG Medicaid payment methodology provides greater reimbursement for high intensity services and relatively less reimbursement for low intensity services. This 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 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.
  2. 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 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.

  3. OASAS APG Service Categories:

    OASAS worked with the Department of Health, the Office of Mental Health, the Office for People with 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 APG categories capture the major behavioral health service groupings that are delivered in OASAS certified outpatient clinics and include:

  4. 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
    Group Counseling
    Medication Management Complex
    Collateral Visit
    Assessment Brief
    Complex Care Coordination
    Assessment Normative
    Peer Counseling
    Assessment Extended
    Addiction Medication Induction/Withdrawal
    Intensive Outpatient Service
    Outpatient Rehabilitation

     

  5. OASAS 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.

    • Clinical Service / Medicaid Billing Manual: PDF Document Combined Ambulatory Patient Groups (APGs) Policy and Medicaid Billing Guidance for OASAS-Certified Outpatient Chemical Dependence Programs. Effective May 2013 this manual has been updated to reflect additional clarification and policy updates.

      • January 2012 APG Rate Code and Reimbursement Amounts Activated for Freestanding Programs. PDF Document

        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.

            OASAS FREESTANDING APG BLEND
            IMPLEMENTATION SCHEDULE

            THIS INFORMATION IS UPDATED AND IS EFFECTIVE AS OF NOVEMBER 2013

            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

            APG Payment

            Phase 1: July 1, 2011 - June 30, 2012

            75%
            25%
            of the full APG Payment
            Phase 2: July 1, 2012 - June 30, 2013
            50%
            50%
            of the full APG Payment
            Phase 3: July 1, 2013 - December 31, 2013
            25%
            75%
            of the Full APG payment
            Phase 4: January 1, 2014
            0
            100%
            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.

      • The APG OASAS Provider Revenue Calculator:
      • Summary of APG payments in OASAS Freestanding programs.

      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.

          Medicaid APG Rate Per Service Upon Full Implementation of APG Payments

          822-4
          Clinic
          Upstate

          Base Rate

          $147.59

          822-4
          Clinic
          Downstate

          Base Rate

          $172.69

          822-5
          Opioid
          Upstate

          Base Rate

          $136.04

          822-5
          Opioid
          Downstate

          Base Rate

          $159.17

          Individual Therapy - Brief

          $91.59 $107.17 $84.43 $98.78

          Psychiatric Assessment - Brief

          Varies due to E&M codes Varies due to E&M codes Varies due to E&M codes Varies due to E&M codes

          Individual Therapy - Normative

          $122.13 $142.90 $112.57 $131.71

          Psychiatric Assessment

          Varies due to E&M codes Varies due to E&M codes Varies due to E&M codes Varies due to E&M codes

          Family/Collateral Therapy

          $91.59 $107.17 $84.43 $98.78

          Group Therapy

          $47.33 $55.38 $43.63 $51.05

          Group Therapy

          $47.33 $55.38 $43.63 $51.05

          Medication Administration & Observation
          (price indicated is for first dose per week subsequent doses in same week discounted 50%)

          See note two at the end of this table.

          $ 39.39
          $46.09
          $36.31
          $42.48

          Assessment - Normative

          $132.31 $154.82 $121.96 $142.70

          Assessment - Extended

          $152.67 $178.63 $140.72 $164.65

          Assessment - Brief

          $41.37 $48.41 $38.13 $44.62

          Screening

          $41.37 $48.41 $38.13 $44.62

          Brief Intervention/Brief Treatment

          $41.37 $48.41 $38.13 $44.62

          Addiction Medication Induction

          $122.13 $142.90 $112.57 $131.71

          Medication Management & Monitoring - Routine

          $50.89 $59.54 $46.91 $54.88

          Medication Management & Monitoring - Complex

          Varies due to E&M codes Varies due to E&M codes Varies due to E&M codes Varies due to E&M codes

          Complex Care Coordination

          $42.75 $50.02 $39.40 $46.10

          Peer Counseling

          $4.61

          $5.40

          $4.25

          $4.98

          Intensive Outpatient Services (IOS)

          $89.93 $105.22 $82.89 $96.98

          Outpatient Rehabilitation - Half Day

          $72.87

          $85.26

          N/A. Opioid programs are not certified as outpatient rehabilitation programs and would not bill as such.

          Outpatient Rehabilitation - Full Day

          $97.16

          $113.68

          N/A. Opioid programs are not certified as outpatient rehabilitation programs and would not bill as such.

          Smoking Cessation Treatment

          $18.70 $21.88 $17.24 $20.17

          Note One: The payments reflected in this table are applicable once APGs have competed the phase in process described in the table titled "OASAS Freestanding APG Blend Implementation Schedule"; and, in the OASAS APG Clinical and Billing Guidance manual.

          Note Two: The enhanced payment for the first dose of the week Medication Administration (H0020) for Opioid Treatment Programs went into effect for dates of service October 3, 2011 forward. For dates of service from July 4, 2011 thru October 2, 2011, the Medicaid APG Rate Per Service upon full implementation of APG payments was:

          Part 822-4 Clinic: US $21.89; DS $25.61

          Part 822-5 Opioid: US $20.17; DS $23.60

          There was no enhanced payment for Medication Administration from July 4, 2011 thru October 2, 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-Based Programs
          Phase Dates
          Freestanding Programs
          Phase Dates
          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
          75% legacy

          25% APG
          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

          50% APG
          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

          75% APG
          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:
          https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician_Billing_Guidelines.pdf

          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.


      • APG OASAS Regulations:
      • Sample Encounter Form: PDF Document 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.
      • Readiness Checklist: PDF Document 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:Microsoft Excel File 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.
  6. 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. PDF Document

    OASAS staff also delivered 11 regional face to face trainings during the summer of 2010.
  7. Questions you may have on OASAS APG implementation may be directed as follows:

    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
    (518) 485-2207

    APG@oasas.ny.gov
    The APG OASAS Provider Revenue Calculator
    APG OASAS Specific Medicaid Billing Questions
    General Medicaid Billing Questions

    Computer Sciences Corporation
    Remedy Call Center

    1-800-343-9000
    general@emedny.org

    Questions Grouper Software/Pricer Product Support
    3M HIS Sales
    3-M Health Information Systems, Inc.
    1-800-435-7776
    1-800-367-2447
    www.3mhis.com