(a) Facilities shall assign ICD-9 diagnostic
codes and HCPCS/CPT procedure codes to each claim as appropriate and shall
submit such information to the department or the department's designee in
accordance with written billing and reporting instructions issued by the
department. the department shall utilize such claim coding information to
assign each the applicable APG or APGs for each patient visit identified on the
claim, utilizing the APG software system to determine the significant procedure
APG or the medical visit APG, the applicable ancillary services APGs and the
final APG weight applicable to each such visit. the APG software system shall
incorporate methodologies for consolidation, packaging and discounting to be
reflected in the final APG weight to be assigned to each visit on the
claim.
(b) The operating component
of the payment rate for each patient shall be computed by multiplying the final
APG weight for each visit, as computed in accordance with subdivision (a) of
this section, by the applicable base rate, as determined in accordance with
section
86-8.7
of this Subpart. A capital component shall then been added to each such payment
rate in accordance with the provisions of section
86-8.4
of this Subpart.
(c) Drugs
purchased under the 340B drug benefit program and billed under the APG
reimbursement methodology shall be reimbursed at a reduced rate comparable to
the reduced cost of drugs purchased through the 340B drug benefit
program.
(d) In cases where the
only reimbursable APGs for a visit are one or more of the following APGs, there
shall be no reimbursement for capital costs included in the payment for that
visit.
94 CARDIAC REHABILITATION
274 PHYSICAL THERAPY, GROUP
275 SPEECH THERAPY AND EVALUATION, GROUP
322 MEDICATION ADMINISTRATION AND OBSERVATION
414 LEVEL I IMMUNIZATION AND ALLERGY IMMUNOTHERAPY
415 LEVEL II IMMUNIZATION
416 LEVEL III IMMUNIZATION
428 PATIENT EDUCATION, INDIVIDUAL
429 PATIENT EDUCATION, GROUP
451 SMOKING CESSATION TREATMENT
(e) The following APGs shall be designated as
"no blend APGs" and shall have their payments calculated solely under the APG
reimbursement methodology.
94 Cardiac Rehabilitation
310 Developmental & Neuropsychological Testing
312 Full Day Partial Hospitalization for Mental
Illness
321 Crisis Intervention
414 Level I Immunization and Allergy Immunotherapy
415 Level II Immunization
416 Level III Immunization
426 Medication Management
428 Patient Education, Individual
429 Patient Education, Group
448 After Hours Services
451 Smoking Cessation Treatment
