NYS Medicaid APG: Understanding Visit and Episode Claiming for Healthcare Providers

NYS Medicaid APG BILLING: VISIT PAYMENT VS. EPISODE CLAIMING FOR ANCILLARY SERVICES

This guide provides healthcare providers with up-to-date information on Ambulatory Patient Group (APG) billing specifically for New York State (NYS) Department of Health (DOH) Medicaid. It focuses on the crucial distinction between visit payment and episode claiming, particularly concerning ancillary services.

An `APG` (Ambulatory Patient Group) is a payment methodology used by NYS Medicaid to reimburse providers for outpatient services, bundling services into groups based on clinical characteristics and resource utilization. This system aims to promote efficiency and fair reimbursement.

Defining a Visit in NYS Medicaid APG Billing

A “visit” is defined as a unit of service consisting of all APG services performed for a patient that are coded on the same claim and share a common date of service. There may be multiple APGs associated with a visit, depending on the services provided. Historically, the “visit” was the basic unit for payment under APG implementation.

Transition to Episode Claiming and Ancillary Services Reimbursement

Under current NYS DOH Medicaid APG guidelines, for hospitals, most ancillary laboratory or radiology services associated with a medical visit and/or a significant procedure billed under the APG payment methodology are the fiscal responsibility of the APG provider. These services must be included on the APG claim, even if they were provided by outside vendors or on different dates of service.

This ancillary policy also applies to `D&TCs` (Diagnostic & Treatment Centers). Consistent with this change, new rate codes were issued for hospital `OPDs` (Outpatient Departments) and `D&TCs` to enable the `EAPG Grouper/Pricer` (Enhanced Ambulatory Patient Group Grouper/Pricer) to recognize an “episode” of care.

An “episode” is defined as a unit of service consisting of all services on a claim, regardless of the coded dates of service. Under episode billing, an episode shall consist of all medical visits and/or procedures provided by a clinic to a patient on a single date of service, plus any associated non-carved-out ancillary laboratory or radiology services, regardless of the ancillary service date. To prevent payment reductions due to excessive packaging, consolidating, or discounting, multiple episodes should not be coded on the same claim.

For `ED` (Emergency Department) services, the significant procedures and/or medical visits comprising the non-carved-out ancillary services portion of an episode need not be on a single date of service and may instead occur on consecutive dates of service, still constituting a single episode.

APG Billing Guidelines: Utilizing Visit and Episode Rate Codes

The EAPG Grouper/Pricer is programmed to use two grouping mechanisms for Medicaid claims processing:

• Visit Grouping Mechanism: Applies APG packaging, consolidation, and discounting to all services on a claim with the same date of service. With visit billing, there can be more than one visit on the claim, and each visit will process separately based on the coded dates of service.
• Episode Grouping Mechanism: Applies APG packaging, consolidation, and discounting to all services on a claim regardless of the date of service. Therefore, on an episode claim, there can be only one visit/episode, and the date of service is ignored by the grouper/pricer for grouping purposes across the episode.

Visit Rate Codes and Ancillary Services Reimbursement

When using visit rate codes to claim for a visit, all associated ancillary laboratory or radiology services must be reported on the same claim as the medical visit or significant procedure that generated the ancillary service. Historically, for claiming purposes, providers often had to reassign the dates of ancillary services to correspond with the date of the primary medical visit or significant procedure. If the dates of the ancillaries were not reassigned, they were likely viewed by the grouper/pricer as “if stand-alone, do not pay procedures,” resulting in no payment.

To avoid the complexities of date reassignment, NYS DOH implemented the episode claiming option. Under episode claiming, correct dates of service can be coded for ancillaries, and they will still group with and be paid with the relevant/associated medical visit or significant procedure. While multiple visits may be reported on the same claim when using visit rate codes, the Grouper/Pricer will apply the APG grouping logic to all services and procedures with the same date of service.

What are “If Stand-Alone, Do Not Pay Procedures”? These are procedures that, when billed in isolation, are not reimbursed under APG rules because their cost is typically ‘packaged’ into a primary service or procedure. For example, certain minor lab tests, supply items, or administrative services might be considered ‘if stand-alone, do not pay’ if not clearly associated with a main visit or procedure that generates an APG. This concept emphasizes the bundled nature of APG reimbursement, where minor services are often considered integral to a larger, primary service.

Claim Submission Rules for Visit and Episode Billing:

• All services and procedures provided to a patient with the same date of service and rate code (based on servicing provider type – e.g., OPD, Ambulatory Surgery Center, ED, and D&TC) must be billed together on one claim.
• If two claims are submitted for the same patient with the same rate code, same date of service, and same provider (hospital or D&TC), only the first claim submitted will result in payment. The second claim will be denied as duplicative.
• Example: If a patient returns to the clinic for multiple visits on the same date, all procedures must be billed on one claim with the appropriate APG rate code (e.g., 1400 for hospital OPDs or 1407 for D&TCs). Attempting to submit multiple APG claims for that rate code for the same recipient/same date will result in only one claim being paid, with others denied as duplicative.
• If a patient is initially seen in the hospital emergency room and the visit ultimately results in a same-day ambulatory surgery service outside of the emergency room, the hospital should bill the visit only under the ambulatory surgery rate code, consolidating all services onto a single claim.

Episode Rate Codes and Episode of Care Definition

As described, for purposes of APG reimbursement, an “episode of care” consists of a medical visit and/or significant procedure that occurred on a single date of service and all the associated ancillary laboratory or radiology services that occurred on or after the date of the medical visit or significant procedure. When using an episode rate code to claim for an episode of care, providers must include a “from” and “to” date in the claim header to reflect the entire episode of care, as well as specific dates at the line level for each service provided as part of the episode.

All procedure codes related to an episode of care should be reported on a single claim with their actual dates of service. This includes the medical visit and/or procedures that occurred on a single date of service and all associated ancillary laboratory or radiology services on or after the medical visit or significant procedure, regardless of the provider or date of service. When using an episode rate code, the `EAPG Grouper/Pricer` will apply the APG grouping logic to all services and procedures on the claim, regardless of the dates of service. If procedures from two different episodes of care are coded on the same claim, unwarranted discounting or consolidation may occur, resulting in underpayment to the APG biller.

As with visit rate codes, if two claims are submitted by the same APG provider for the same patient, using the same episode rate code and the same “from” date for the episode of care, only the first claim submitted will result in payment. The second claim will be denied.

Under current **NYS DOH Medicaid APG billing guidelines**, D&TCs are expected to incorporate ancillary laboratory and radiology services provided directly by the clinic or historically included in the clinic’s former threshold or specialty payment onto the APG claim. `eMedNY` provides further guidance on the comprehensive ancillary billing policy.

NYS DOH strongly encourages providers assigned episode rate codes (hospital OPDs, D&TCs, and `SBHCs` (School-Based Health Centers)) to use episode rate codes for most claims. Exceptions may include billing for Medicare/Medicaid dual eligibles or for services routinely billed on a monthly basis. Episode rate codes generally enable more accurate reporting with respect to the date of ancillary lab and radiology services and, when used properly, will always result in as much or more payment than using a visit rate code for the same bundle of services.

Medicaid Claims Processing: Updated Units of Service Guidelines

Generally, the APG reimbursement system does not extensively recognize units of service. However, NYS DOH Medicaid APG guidelines allow for multiple units of service for a limited group of procedures, which currently includes:

• Physical and occupational therapy
• Nutrition counseling (e.g., CPT 97802 for medical nutrition therapy, individual, 15 minutes)
• Crisis management (e.g., CPT H2011 for crisis intervention service, 15 minutes)
• Patient education, including diabetes and asthma self-management services rendered by `CDEs` (Certified Diabetes Educators) and `CAEs` (Certified Asthma Educators)
• Health/behavioral assessments (e.g., CPT 96150 for initial assessment of health behavior)

Providers should not code multiple lines on a single claim with the same `HCPCS` code (except for specific dental procedures such as multiple teeth sealed, multiple fillings, etc., for which specific guidance is available in **NYS DOH Medicaid APG documentation**) to signify the provision of multiple units of a single procedure/service. Instead, they should include the `HCPCS` code on one line along with the number of units of the service provided on that same line. For physician-administered drugs and all other services billed in multiple units, providers should bill for each drug or service on a single claim line and identify the units provided on that line. Drug APGs are generally set to pay for the average units billed for each APG, based on the costs of a typical dosage. When multiple immunizations are rendered on the same date of service, the APG claim should include multiple codes for the administration of the vaccine. The first administration code will typically pay at 100%, with subsequent codes discounted (e.g., at 50%).

For a complete and current list of units-based procedures and their respective unit maximums, please consult the **official NYS DOH Medicaid APG resources** available on https://www.health.ny.gov/.

Emergency Room – Episode of Care Definition for APG Billing

If a patient enters the `ED` (Emergency Department) before midnight and leaves after midnight, the `EAPG Grouper/Pricer` will treat the ED visit as a single episode of care. A single claim should be filed for each ED visit (episode of care), and the actual dates of service for each procedure should be reported on the claim. All ED services should be billed using the ED rate code, 1402, for **NYS Medicaid claims processing**.

APG Payment Methodology: Understanding Utilization Thresholds

The Utilization Threshold Program continues to apply to clinic services billed as visits or episodes of care under APGs in NYS Medicaid. Under this program, clinic providers must obtain an authorization from the `MEVS` (Medicaid Eligibility Verification System) to render services to Medicaid patients. This authorization is granted unless a recipient has reached their utilization threshold limit. If the individual’s threshold has been reached, the clinic physician must submit a `TOA` (Threshold Override Application) in order to obtain approval for the additional services.

The Utilization Threshold Program provides individualized thresholds, which are refreshed quarterly, for every Medicaid recipient based on their health risk status. Providers can access the latest `TOA` forms and comprehensive guidance on the **NYS DOH Medicaid** or https://www.emedny.org/ website. It is critical to stay informed of the latest updates to these policies.

eMedNY: APG Claim Submission Rules and Remittance

The 835 electronic remittance advice provides detailed line-level information crucial for **Medicaid claims processing**, including the APG code, APG full weight, APG allowed percentage, APG paid amount, the payment based on existing operating reimbursement (the blend amount), “combined with CPT” (if reimbursement for a particular CPT/APG has been consolidated or packaged within another CPT/APG, this field indicates the CPT/APG to which payment has been consolidated/packaged), capital add-on amount, and the total payment for the claim. The 835 Companion Guide, which provides detail for all the APG remittance changes, is now available on the www.eMedNY.org website under NYHIPAADESK.

NYS Medicaid APG FAQ:

Q: How do current APG rules affect billing for dual-eligible (Medicare/Medicaid) patients?

A: For dual-eligible patients, NYS DOH Medicaid APG billing typically follows Medicare’s payment first. The remaining balance, if any, is then submitted to Medicaid. Specific rules may dictate whether visit or episode rate codes are appropriate for these secondary claims, often allowing visit-based codes even after episode claiming became standard for other patients. Providers should consult the latest **NYS DOH Medicaid billing guidelines** for dual-eligible specific instructions.

Q: What are the current utilization thresholds and override procedures?

A: Current utilization thresholds are individualized for each Medicaid recipient based on their health risk status and are regularly refreshed. Providers must consult the `MEVS` (Medicaid Eligibility Verification System) for specific recipient thresholds. Override procedures require submitting a `TOA` (Threshold Override Application) with appropriate medical justification, following **NYS DOH** guidelines accessible via https://www.emedny.org/.

Q: What is the latest guidance on reporting multiple units of service?

A: For procedures where multiple units are recognized (a limited list including therapies, counseling, and education), the current guidance is to report the `HCPCS` code on a single claim line and specify the total number of units provided on that same line. Avoid multiple lines for the same `HCPCS` code unless specifically indicated for certain exceptions (e.g., dental procedures). For detailed information, refer to the **official NYS DOH Medicaid APG resources** on https://www.health.ny.gov/.