Current through Register Vol. 46, No. 39, September 25, 2024
(a)
Definitions.
Definitions pertaining to the ambulatory patient croup
classification and reimbursement methodology can be found in 10 NYCRR section
86-8.2. Additional definitions are as follows:
(1) Coding improvement factor. A numeric
value which OPWDD may use to adjust for more complete and accurate coding for
visits upon implementation of the APG reimbursement system.
(2) Evaluation and management (E&M)
services. Services and/or consultations as designated by CPT provided by a
physician, nurse practitioner or an appropriately supervised physician
assistant.
(b)
Ambulatory patient groups (APG).
For services provided on or after July 1, 2011, the operating
component of rates shall be reimbursed using a methodology that is prospective
and is based upon the APG classification and reimbursement system as described
in 10 NYCRR sections 86-8.2, 86-8.7, 86-8.9(a), 86-8.10 and 86-8.11(b).
(c)
Operating
component.
The operating component of the rates is the product of the
peer group base rate times the procedure's allowed relative APG weight or the
final APG weight for each APG on a claim.
(1) The base rates.
There shall be a separate base rate for each peer group.
OPWDD's three peer groups and base rates are as follows:
(i) Peer Group A. Except for clinics
described in subparagraph (iii) of this paragraph, Peer Group A shall be
comprised of clinic treatment facilities that have the certified main clinic
site located in New York City or Long Island, i.e., the
counties of New York, Bronx, Kings, Queens, Richmond, Nassau and Suffolk. The
base rate for Peer Group A is $180.95.
(ii) Peer Group B. Except for clinics
described in subparagraph (iii) of this paragraph, Peer Group B shall be
comprised of clinic treatment facilities that have the certified main clinic
site located in a county other than those identified in subparagraph (i) of
this paragraph. The base rate for Peer Group B is $186.99.
(iii) Peer Group C. Clinic treatment
facilities that are affiliated with and serve two major hospital systems and
have the following Federal designations as of July 1, 2011:
(a) University Center for Excellence in
Developmental Disabilities (UCEDD) by the United States Department of Health
and Human Services' Administration on Developmental Disabilities (ADD);
and
(b) National Institutes for
Health's (NIH's) Eunice Kennedy Shriver National Institute of Child Health and
Human Development Intellectual and Developmental Disability Research Center
(IDDRC); and
(c) Maternal and Child
Health Bureau (MCHB), Health Resources and Services Agency of the United States
Public Health Service, Leadership Education in Neurodevelopmental and Related
Disabilities (LEND) training program.
The base rate for Peer Group C is $270.50.
(2) APGs and APG
relative weights are listed in 10 NYCRR section 86-8.7.
(d)
Capital cost component.
If a visit includes a service which maps to an APG which
allows a capital add-on, there shall be a capital add-on to the operating
component of the APG payment for the visit.
(1) The capital cost component shall be a
fixed amount equal to the capital cost component of the clinic's regular visit
fee in effect on June 30, 2011.
(2)
Beginning July 1, 2012, OPWDD shall subject the capital cost component to an
annual review for certain clinic treatment facilities.
(i) Clinics specifically subject to review
are those which:
(a) had operating
certificates for a diagnostic and treatment center issued by the NYS DOH
pursuant to article 28 of the Public Health Law; and
(b) transferred long term therapeutic and
clinical habilitative services on or after April 1, 2009 to an operating
certificate for a clinic treatment facility issued by OPWDD pursuant to article
16 of the Mental Hygiene Law; and
(c) received funding of the property
component in an amount equal to the previously approved article 28 DOH
diagnostic and treatment center property component.
(ii) OPWDD's review shall consist of a
comparison of the capital cost reimbursement in effect at the time of its
review to the clinic's actual capital expenditures as reflected in its annual
financial report submitted for the period two years prior to the period subject
to revision.
(iii) For those
clinics reviewed pursuant to this paragraph, the capital cost component shall
be the lesser of:
(a) the most recent
reimbursement; or
(b) the greater
of:
(1) the actual capital expenditures;
or
(2) the amount reimbursed to
clinic treatment facilities certified by OPWDD which do not meet the criteria
specified in subparagraph (i) of this paragraph.
(e) Clinic
services not paid based upon the APG classification and reimbursement system
are described in 10 NYCRR section 86-8.10 Exclusions from payment.
