(a) This section shall govern Medicaid rates of payments for OASAS certified or co-certified ambulatory care services provided in the following categories of facilities:

1. (1) chemical dependence outpatient clinics certified or co-certified pursuant to Part 822 of this Title;
2. (2) opioid treatment clinics certified or co-certified pursuant to Part 822 of this Title;
3. (3) chemical dependence outpatient rehabilitation programs certified or co-certified pursuant to Part 822 of this Title.

(b) Notwithstanding subdivision (a) of this section, the provisions of this Part shall not apply to the following:

1. (1) hospital based chemical dependence outpatient clinics;
2. (2) hospital based opioid treatment providers; and

3. (3) payments made on behalf of persons enrolled in Medicaid managed care or in the family health plus program.

   (c) Definitions.

   As used in this Part, the following definitions apply:

4. (1) Ambulatory patient group (APG) shall mean a defined group of outpatient procedures or services which reflect similar patient characteristics and resource utilization and which incorporate the ICD-9-CM diagnosis codes and CPT and HCPCS procedure codes as defined below.
5. (2) Ancillary services shall mean those laboratory and radiology tests and procedures ordered to assist in patient diagnosis and/or treatment.
6. (3) APG weight shall mean a numeric value that reflects the relative expected average resource utilization (cost) for each APG as compared to the expected average utilization for all other APG's. Procedure- based APG weight shall mean a numeric value that reflects the relative expected average resource utilization (cost) for a specific procedure. A procedure that has been assigned to its own weight shall have its payment derived from its procedure-specific weight without regard to the weight of the APG to which the procedure groups.
7. (4) Base rate shall mean the numeric value that must be multiplied by the APG weight for a given APG to determine the total Medicaid payment for a service.
8. (5) Case mix index shall mean the actual or estimated average final APG weight for a defined group of APG visits.
9. (6) Coding improvement factor (CIF) is a numeric value used to adjust for more complete and accurate coding for visits upon implementation of the APG reimbursement system. The CIF will be developed to assure that New York Department of Health is in full compliance with federally approved reimbursement levels.
10. (7) Consolidation/bundling shall mean the process for determining if a single amount is appropriate in those circumstances when a patient receives multiple APG procedures during a single patient visit. In some cases, a procedure will be considered part of a more complicated procedure. In this case, the payment for the less complicated procedure will be included in the payment for the more complicated procedure and the claim line for the less complicated procedure will show zero payment for that procedure. Consolidation logic is defined in the 3M Health Information Systems' APG Definitions Manual version 3.1 dated March 6, 2008 and as subsequently amended by 3M.
11. (8) Current procedural terminology (CPT) codes is the systemic listing and coding of procedures and services provided to a patient. It is a subset of the healthcare procedure coding system (HCPCS). The CPT and HCPCS are maintained by the American Medical Association and the Federal Centers for Medicare and Medicaid Services (CMS) and are updated annually.
12. (9) Discounting shall mean the reduction in APG payment that results when unrelated, additional procedures or ancillary services are performed during a single patient visit.
13. (10) Episode shall mean a unit of service consisting of all services coded on a claim. All services on the claim are considered to be part of the same APG visit and are not segmented into separate visits based on coded dates of service as would be the case with "visit" billing. Under episode billing, an episode shall consist of all medical visits and/or significant procedures that are provided to a patient on a single date of service plus any ordered ancillaries, ordered on the date of the visit or date of the significant procedure(s), resulting from the medical visits and/or significant procedures, some of which may have been done on a different date of service from that of the medical visits and/or significant procedures. Multiple episodes cannot be coded on the same claim. The calculation of the APG payment by the APG software may be either visit based or episode-based depending on the rate code used to access the APG software logic. References to "visits" in this Part shall be deemed to refer also to "episodes" for billing purposes.
14. (11) Existing payment for blend shall mean the reimbursement rate/fee in effect on June 30, 2011.
15. (12) Final APG weight shall mean the allowed APG weight for a given visit as expressed by the applicable APG software, and as adjusted by all applicable consolidation, packaging, discounting and other applicable adjustments.
16. (13) Healthcare common procedure coding system (HCPCS codes) shall mean a comprehensive, standardized coding and classification system for health services and products.
17. (14) Hospital based shall mean a program that is operated by and certified as a hospital pursuant to article 28 of the Public Health Law and identified as such by the Department of Health.
18. (15) International Classification of Diseases means the most current version of this comprehensive coding system maintained by the Federal Centers for Medicare and Medicaid Services maintained for the purpose of providing a standardized, universal coding system to identify and describe patient diagnosis, symptoms, complaints, conditions and/or causes of injury or illness. It is updated annually.
19. (16) Packaging shall mean those circumstances in which payment for routine ancillary services or drugs shall be deemed as included in the applicable APG payment for a related significant procedure or medical visit. Medical visits also package with significant procedures, unless specifically excepted in regulation. There is no packaging logic that resides outside the software.
20. (17) Peer group shall mean a group of providers that share a common APG base rate. Peer groups may be established based on geographic region, types of services provided or categories of patients.
21. (18) The downstate region shall consist of the five counties compromising New York City, and the counties of Nassau, Suffolk, Westchester, Rockland, Orange, Putnam, and Dutchess.
22. (19) The upstate region shall consist of all counties in the State other than those counties included in the downstate region.

23. (20) Visit shall mean a unit of service consisting of all the APG services performed for a patient on a single date of service.

    (d) System transition.

    There will be a transition to APG reimbursement consisting of a blended payment. For chemical dependence outpatient clinics it will be comprised of an existing payment for blend portion of the fees established pursuant to 18 NYCRR section 505.27 and the APG reimbursement established pursuant to this Part. For opioid treatment clinics it will be comprised of an existing payment for blend portion of the fees established pursuant to 10 NYCRR section 86-4.39 and the APG reimbursement established pursuant to this Part. The blended payment will be calculated as follows:

24. (1) the office shall identify the existing payment for blend payment for each provider based upon the reimbursement rate/fee in effect on June 30, 2011; and

25. (2) payments will be made pursuant to the following transition schedule:

    1. (i) phase 1 shall be the 12 month period beginning on July 1, 2011. Providers shall receive 75 percent of the existing payment for blend payment and 25 percent of the calculated value of the APG reimbursement established pursuant to this Part;
    2. (ii) phase 2 shall be the 12 month period following Phase 1. Providers shall receive 50 percent of the existing payment for blend payment and 50 percent of the calculated value of the APG reimbursement established pursuant to this Part;
    3. (iii) phase 3 shall be the six month period following Phase 2. Providers shall receive 25 percent of the existing payment for blend payment and 75 percent of the calculated value of the APG reimbursement established pursuant to this Part;

    4. (iv) phase 4 providers will receive 100 percent APG reimbursement established pursuant to this Part.

       (e) APG Categories and associated weights.

26. (1) APG categories shall be subject to periodic revision; the most current listing shall be published in the APG Policy and Medicaid Billing Guidance manual available on the OASAS website.

27. (2) The Department of Health, in consultation with the office shall assign weights associated with all CPT and HCPCS procedure codes which can be used to bill any APG category. The assigned weights shall be set forth at 10 NYCRR Part 86. The office shall maintain and update a list of weights associated with APG categories as published in the APG Policy and Medicaid Billing Guidance manual on the OASAS website. Such list may include APG categories not specifically associated with chemical dependency outpatient and opioid treatment services, but which may appropriately be billed by providers subject to this Part.

    (f) Base rates.

    Base rates for chemical dependence outpatient services shall be developed by the office, and subject to the approval of the Department of Health, in accordance with the following:

28. (1) separate base rates shall be established for each peer group as defined in this section. Base rates shall reflect differing regional cost factors, variations in patient population and service delivery, and capital reimbursement;
29. (2) additional discrete base rates may be developed by the office for such peer groups as may be established by regulation in this Part; and

30. (3) base rates may be periodically adjusted to reflect changes in provider case mix, service costs and other factors as determined by the office.

    (g) System updating.

31. (1) The following elements of the APG rate-setting system shall be reviewed at least annually, with all changes posted on the office's website:

    1. (i) the listing of reimbursable APG categories and associated weights assigned to each such APG set forth in this Part;
    2. (ii) the base rates;
    3. (iii) the applicable ICD-9 codes, or subsequent ICD categorization, utilized in the APG software system;
    4. (iv) the applicable CPT/HCPCS codes utilized in the APG software system; and

    5. (v) the APG software system.

       (h) Medicaid claims.

       Medicaid claims may be submitted for claims made under Medicaid fee-for-service for no more than two different services per day for any patient, not including complex care coordination, medication administration and observation, medication management and peer support services.

       (i) Billing services.

       Billing services include:

32. (1) Admission assessment services. Admission assessment services consist of three levels of billable services: brief assessment, normative assessment and extended assessment. No more than one admission assessment visit may be billed for any patient per day. No more than three admission assessment visits may be billed for any patient within an episode of care. No single program may bill for more than one extended assessment, under any circumstances, within an episode of care.

    1. (i) Brief assessment. The program must document at least 15 minutes of face-to-face contact with the patient.
    2. (ii) Normative assessment. The program must document at least 30 minutes of face-to-face contact with the patient.
    3. (iii) Extended assessment. The program must document at least 75 minutes of face-to-face contact with the patient.
33. (2) Brief intervention. No more than one brief intervention may be billed for any patient per day. No single program may bill more than three pre-admission brief intervention services for any patient within an episode of care. The program must document at least 15 minutes of face-to-face contact with the patient.
34. (3) Brief treatment. No more than one brief treatment may be billed for any patient per day. The program must document at least 15 minutes of face-to-face contact with the patient.
35. (4) Collateral visit. No more than one collateral visit may be billed for any patient per day. No more than five collateral visits may be billed for any patient within an episode of care. The program must document at least 30 minutes of face-to-face contact with the collateral person. A collateral visit may occur at any time during an episode of care.
36. (5) Complex care coordination. No more than one complex care service may be billed for any patient per day. No more than three complex care services may be billed for any patient within an episode of care, unless clinical staff document in the treatment/recovery plan that additional complex care services are clinically necessary and appropriate. The program must document at least 45 minutes of services. Service time need not be consecutive. This service must occur within five working days of another program visit that includes a billable service.
37. (6) Group counseling. No more than one group counseling service may be billed for any patient per day. The program must document at least 60 minutes of face-to-face contact with the patient.

38. (7) Individual counseling. No more than one individual counseling service may be billed for any patient per day. Individual counseling consists of two billable levels of service: brief individual counseling and normative individual counseling.

    1. (i) Brief individual counseling. The program must document at least 25 minutes of face-to-face contact with the patient.
    2. (ii) Normative individual counseling. The program must document at least 45 minutes of face-to-face contact with the patient.
39. (8) Intensive outpatient services (IOS). No more than six weeks of IOS may be billed for any patient. However, additional IOS may be provided, if during the final week of scheduled IOS, clinical staff document in the treatment/recovery plan that additional IOS are clinically necessary and appropriate. The program must document a minimum of nine scheduled service hours per week to be provided in increments of at least three hours per day. Where a patient fails to receive a full daily increment of services, a program may bill for delivery of any services defined in Part 822 of this Title.
40. (9) Medication administration and observation. No more than one medication administration and observation service may be billed for any patient per day. This service may be of any duration. The program must document face-to-face contact with the patient.

41. (10) Medication management. Medication management consists of three levels of billable services: routine medication management, complex medication management and addiction medication induction. No more than one medication management service may be billed for any patient per day.

    1. (i) Routine medication management. The program must document at least 10 minutes of services including face-to-face contact with the patient and patient observation.
    2. (ii) Complex medication management. The program must document at least 15 minutes of services including face-to-face contact with the patient and patient observation.
    3. (iii) Addiction Medication Induction. The program must document at least 30 minutes of services including face-to-face contact with the patient and patient observation.

42. (11) Outpatient rehabilitation services. No more than one outpatient rehabilitation service may be billed for any patient per day. Programs that provide outpatient rehabilitation services may also bill for medication administration and observation, medication management, complex care coordination, peer support services and collateral visits consistent with the standards set forth in this subdivision. Programs may not bill for any other service categories while a patient is admitted to the outpatient rehabilitation service. Outpatient rehabilitation services consist of two billable levels of service: 2-4 hour duration and 4 hour and above duration.

    1. (i) 2-4 hour duration. The program must document at least 2 hours of services but less than 4 hour hours of services.
    2. (ii) 4 hour and above duration. The program must document at least 4 hours of services.
43. (12) Peer support service. No more than one peer support service may be billed for any patient per day. No more than five peer support services may be billed for any patient within an episode of care, unless clinical staff document in the treatment/recovery plan that additional peer support services are clinically necessary and appropriate. The program must document at least 30 minutes of face-to-face contact with a patient.
44. (13) Screening. No more than one screening may be billed for any patient within an episode of care. The program must document at least 15 minutes of face-to-face contact with the patient.