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The Board transitioned to a new Ambulatory Surgery Fee Schedule based on Enhanced Ambulatory Patient Groups (EAPG) effective October 1, 2015. To learn about the EAPG methodology, please see the 3M EAPG Presentation adobe pdf.

  1. What services are covered by the New York State Workers' Compensation (NYS WC) Ambulatory Surgery Fee Schedule?

    The NYS WC Ambulatory Surgery Fee Schedule covers outpatient ambulatory surgery in hospital-based or free-standing ambulatory surgery centers (ASC). Inpatient stays are reimbursed by APR-DRG methodology.

  2. Does this apply to No Fault?

    The Workers' Compensation Board (Board) does not oversee No Fault. Any questions regarding No Fault, including payment of Ambulatory Surgery, Emergency Department Services, Clinic Services and Private Psychiatric Hospital Services should be directed to the Department of Financial Services. See www.dfs.ny.govLink to External Website.

  3. Is the NYS WC Ambulatory Surgery Fee Schedule posted or must we calculate payments?

    The NYS WC Ambulatory Surgery Fee Schedule is not posted. Stakeholders may calculate payments using 3M Grouper software, or manually.

  4. Is the software available? Can billers purchase the software? How much does it cost?

    The 3M Core Grouper software or cloud-based 3M Grouper Plus Content Services (GPCS) is available. Any organization that processes health care claims may purchase the software. It is available for many reimbursement systems including Medicare, Medicaid, Tricare and NYS WC Ambulatory Surgery bills. For information on pricing, please contact 3M directly.

  5. What is 3M's contact information?

    Cori Parkinson - cparkinson@mmm.com customer inquiries

    Population and Payment Solutions
    3M Health Information Systems
    Office: 801-265-4395
    www.3Mhis.comLink to External Website

  6. Does an insurance company send provider bills to the Board to reprice and send back for payment?

    An insurance company must reprice and pay bills per the EAPG methodology. The Board does not reprice bills.

  7. Is the bundling/consolidation in Encoder Pro the same as the bundling/consolidation in 3M Core Grouper?

    Encoder Pro is not a 3M product. The vendor that produces Encoder Pro should be contacted regarding the specifics of that product's packaging and consolidation rules.

  8. Where do I find the rates for my facility?

    Rates can be found on the New York State Department of Health (NYS DOH) Ambulatory Patient Groups (APG) pageLink to External Website under reimbursement requirements.

  9. Is there a difference in billing for hospital-based vs. free-standing ambulatory surgery services?

    Both hospitals and ambulatory surgery centers (ASC) would bill using Form UB-04. The same base rates are used for services provided in a hospital as well as an ASC. However, the capital add-on values differ for hospitals and ASCs. Additionally:

    1. Hospitals would bill using rate code 1401
    2. Out-of-state hospitals would use rate code 1416
    3. ASC would use rate code 1408
    4. Rate code 1401 Upstate - Workers' compensation base rate: $228.62, Capital add-on payment: $108.48
    5. Rate code 1401 Downstate - Workers' compensation base rate: $295.94, Capital add-on payment: $115.70
    6. Rate code 1408 Upstate - Workers' compensation base rate: $228.62, Capital add-on payment: $109.90
    7. Rate code 1408 Downstate - Workers' compensation base rate: $295.94, Capital add-on payment: $81.37

  10. Are rate codes required to be on the bill?

    Yes. The appropriate rate codes can be found on the NYS DOH website. Bills submitted without rate codes can be rejected.

    The Board does not authorize ASCs or hospitals. Any New York State hospital that performs outpatient surgery and/or NYS DOH Article 28 approved ASC submitting a bill should be reimbursed. If a facility-specific value is not present, the rate should be calculated by creating a generic table within the 3M Core Grouper software. Directions for creating a generic table within the 3M Core Grouper are available on the Board's website. Please refer to FAQ number 9 for the rate codes and related rates.

  11. What form should be submitted for ambulatory surgery bills?

    Ambulatory surgery procedures should be billed on Form UB-04.

  12. Where are the EAPG codes entered on Form UB-04? Are they a required part of the bill? If the EAPG codes are not submitted with a bill, should it be rejected?

    The EAPG codes are not a required part of the bill. Providers/facilities can provide Current Procedural Terminology (CPT) codes. Bills should not be rejected if the EAPG codes are not listed.

  13. What is the difference between an episode of care and a visit?

    A visit is "a unit of service consisting of all the APG services performed for a patient that are coded on the same claim and share a common date of service." This type of billing applies to ambulatory surgery. An episode is "a unit of service consisting of all services on a claim, regardless of the coded dates of service." This type of billing applies to clinic and emergency department billing and is not applicable to ambulatory surgery billing.

    These definitions can be found in the APG Provider Manual.

  14. Are prior year or deleted CPT codes included?

    EAPGs codes cover all current CPT codes. A crosswalk to assist stakeholders in mapping prior or deleted CPT codes to current CPT codes is available on the Board's website.

  15. Does EAPG cover codes not listed in Products of Ambulatory Surgery (PAS)?

    The EAPG methodology maps appropriate current CPT procedures to the International Classification of Diseases, Tenth Revision (ICD-10) codes.

  16. Where is the logic to consolidate edits?

    The EAPG consolidation logic can be found on the NYS DOH websiteLink to External Website.

  17. Which National Correct Coding Initiative (NCCI) edits are used?

    Hospital outpatient NCCI edits and Medical Unlikely edits are used.

  18. Is pre-op testing included in the EAPG?

    Pre-op testing should be billed using the New York State Workers' Compensation Medical Fee Schedule in effect at the time the services were provided. Only pre-op testing occurring on the same day as the procedure by the facility performing the procedure would be included in the EAPG reimbursement.

  19. Does each facility's Operating Certificate (OpCert) number contain their EAPG rate?

    NYS DOH issues EAPG rates for Medicaid upon request based on a facilities National Provider Identifier (NPI) and OpCert number. However, payment can be calculated generically without an NPI or OpCert number to cover Workers' Compensation reimbursements. Directions for creating a generic table within the 3M Core Grouper are available on the Board's website.

    The Board does not authorize ASCs or hospitals. Any NYS hospital that performs outpatient surgery and/or NYS DOH Article 28 approved ASC submitting a bill should be reimbursed. If a facility-specific value is not present, the rate should be calculated generically using the following guidance or by creating a generic table within the 3M Core Grouper software. Please refer to FAQ number 9 for the rate codes and related rates.

  20. Why doesn't the 150% increase apply to the capital add-on value amount?

    The capital add-on value is an amount provided by NYS DOH based on approved cost of capital. Certain EAPGs include the cost of capital and would not result in an additional capital add-on payment. However, these EAPGs would receive a 150% increase over Medicaid using the NYS Workers' Compensation specific base rate.

  21. If the maximum rate code is zero for capital add-on, does that mean there is nothing payable?

    The capital add-on is not a percentage of the payment for the other services. It is a set fixed dollar amount. There can be payment for the services, derived from the EAPG grouping, even if the capital add-on value is zero. Normally, the capital add-on value is not zero, but there are a few exceptions where there is no capital add-on for certain services.

  22. Can modifier 59 be removed from a bill?

    The bill should be calculated as submitted by the facility. The payer has the right to raise legal or valuation issues in a timely manner on the appropriate form.

  23. How does NYS WC Ambulatory Surgery Facility Fee Schedule provide for reimbursement of implants used as part of a surgical procedure?

    EAPG payment is based on the severity of an episode of care. The 2015 EAPG fee schedule has a NYS Workers' Compensation specific base rate that pays 150% of Medicaid hospital rates for upstate and downstate regions and includes the cost of implants in the relative weight of the procedure. Implants are not reimbursed as an add-on, and should be billed using the appropriate Healthcare Common Procedure Coding System (HCPCS).

  24. Do you report modifier 59 or F1, F2 etc. with CPT code 26055 for multiple trigger finger releases?

    For consistency, the appropriate modifier on the facility bill should be the same as that reported on the provider bill for multiple body parts.

  25. Does claimant gender and birthday affect EAPG assignment?

    Age and gender do affect some EAPG assignments. In addition, there are some ICD-10-CM (Clinical Modification) diagnosis codes and certain CPT/HCPCS procedure codes that are age and gender sensitive.

Resources


Emergency Department Fee Schedule

  1. How are services provided by emergency departments reimbursed?

    All hospital outpatient emergency department services are reimbursed according to the New York State Workers' Compensation (NYS WC) Emergency Department Fee Schedule, effective July 15, 2019. Rates are established at 150% of the New York State Medicaid Base Rate for upstate and downstate regions. Payments are calculated using NYS WC Enhanced Ambulatory Patient Group (EAPG) methodology.

    If, upon being evaluated in the emergency department, the injured worker is admitted to the hospital, the entire episode of care is considered an inpatient stay and paid using APR-DRG methodology.

  2. What form should be submitted for emergency department bills?

    Emergency department bills should be billed on Form UB-04.

  3. Are rate codes required to be on the bill?

    Yes. The appropriate rate code for hospital emergency departments is 1402 for in-state hospital emergency departments and 1419 for out-of-state hospital emergency departments. The table below gives the emergency department codes and the New York State Department of Health (NYS DOH) EAPG base rates.

    Service Type *Base Rate Visit Code NYS DOH EAPG Base Rates Base Rate Effective Date NYS WC EAPG Base Rates July 15, 2019
    DOWNSTATE UPSTATE DOWNSTATE UPSTATE
    Emergency Department 1402 $197.38 $154.15 May 1, 2012 $296.07 $231.23
    Emergency Department 1419 $197.38 $154.15 May 1, 2012 $296.07 $231.23

    *Schedule provides base rates only. For the capital add-on values, refer to the Rate by Provider files on the NYS DOH website.

  4. Will a new fee schedule be posted or must we calculate payments?

    An NYS WC Emergency Department Fee Schedule will not be posted. Stakeholders may calculate payments through the use of the 3M Grouper software.

  5. Does this apply to No Fault?

    The Workers' Compensation Board (Board) does not oversee No Fault. Any questions regarding No Fault, including payment of emergency department bills, should be directed to the Department of Financial ServicesLink to External Website.

  6. Is the software available? Can billers purchase the software? How much does it cost?

    The 3M Core Grouper software or cloud-based 3M Grouper Plus Content Services (GPCS) is available. Any organization that processes health care claims may purchase the software. It is available for many reimbursement systems, including Medicare, Medicaid, Tricare and NYS Workers' Compensation Ambulatory Surgery bills. For information on pricing, please contact 3M directly.

  7. What is 3M's contact information?

    Cori Parkinson - cparkinson@mmm.com customer inquiries

    Population and Payment Solutions
    3M Health Information Systems
    Office: 801-265-4395
    www.3Mhis.comLink to External Website

  8. Is the bundling/consolidation in Encoder Pro the same as the bundling/consolidation in 3M Core Grouper?

    Encoder Pro is not a 3M product. The vendor that produces Encoder Pro should be contacted regarding the specifics of that product's packaging and consolidation rules.

  9. Where do I find the rates for my facility?

    Rates can be found on the New York State Department of Health (NYS DOH) Ambulatory Patient Groups (APG) pageLink to External Website under reimbursement requirements.

  10. Are rate codes required to be on the bill?

    Yes. The appropriate rate codes can be found on the NYS DOH website. Bills submitted without rate codes can be rejected.

  11. Did the Board adopt the Medicaid Never Pay list?

    The Board adopted the Medicaid Never Pay list.

  12. Where is the logic to consolidate edits?

    The EAPG consolidation logic can be found on the NYS DOH websiteLink to External Website.

  13. Which National Correct Coding Initiative (NCCI) edits are used?

    Hospital outpatient NCCI edits and Medical Unlikely edits are used.

  14. Why doesn't the 150% increase apply to the capital add-on value amount?

    The capital add-on value is an amount provided by NYS DOH based on approved cost of capital. Certain EAPGs include the cost of capital and would not result in an additional capital add-on payment. However, these EAPGs would receive a 150% increase over Medicaid using the NYS Workers' Compensation specific base rate.

  15. If the maximum rate code is zero for capital add-on, does that mean there is nothing payable?

    The capital add-on is not a percentage of the payment for the other services. It is a set fixed dollar amount. There can be payment for the services, derived from the EAPG grouping, even if the capital add-on value is zero. Normally, the capital add-on value is not zero, but there are a few exceptions where there is no capital add-on for certain services.

  16. Can modifier 59 be removed from a bill?

    The bill should be calculated as submitted by the facility. The payer has the right to raise legal or valuation issues in a timely manner on the appropriate form.

  17. Does claimant gender and birthday affect EAPG assignment?

    Age and gender do affect some EAPG assignments. In addition, there are some ICD-10-CM (Clinical Modification) diagnosis codes, certain Current Procedural Terminology (CPT) codes, and Healthcare Common Procedure Coding System (HCPCS) codes that are age and gender sensitive.

Resources


Rural Outpatient Clinic Services Fee Schedule (Primary Care Only)

  1. What is the difference between an episode of care and a visit?

    A visit is "a unit of service consisting of all the APG services performed for a patient that are coded on the same claim and share a common date of service." This type of billing applies to ambulatory surgery. An episode is "a unit of service consisting of all services on a claim, regardless of the coded dates of service." This type of billing applies to clinic and emergency department billing and is not applicable to ambulatory surgery billing.

  2. Are rate codes required to be on the bill?

    Yes. The appropriate rate code for rural outpatient clinics (primary care only) is 1407. The table below gives the emergency department codes and the New York State Department of Health (NYS DOH) EAPG base rates.

    Service Type *Base Rate Visit Code NYS DOH EAPG Base Rates Base Rate Effective Date NYS WC EAPG Base Rates July 15, 2019
    DOWNSTATE UPSTATE DOWNSTATE UPSTATE
    Clinic (Rural Outpatient Clinic) 1407 - $141.64 July 15, 2019 - $141.64

    *Schedule provides base rates only. For the capital add-on values, refer to the Rate by Provider files on the NYS DOH website.

Resources


Hospital Based Mental Health Clinic Services Fee Schedule

  1. What is the difference between an episode of care and a visit?

    A visit is "a unit of service consisting of all the Ambulatory Patient Group (APG) services performed for a patient that are coded on the same claim and share a common date of service." This type of billing applies to ambulatory surgery. An episode is "a unit of service consisting of all services on a claim, regardless of the coded dates of service." This type of billing applies to clinic and emergency department billing and is not applicable to ambulatory surgery billing.

  2. Are rate codes required to be on the bill?

    Yes. The appropriate rate codes can be found on the New York State Office of Mental Health (NYS OMH) websiteLink to External Website.

    NYS OMH Clinic Rate Codes *Base Rate Visit Code NYS OMH EAPG Base Rates Base Rate Effective Date NYS WC EAPG Base Rates July 15, 2019
    DOWNSTATE UPSTATE DOWNSTATE UPSTATE
    Base Rate 1516 $181.16 $139.25 April 1, 2019 $181.16 $139.25
    Off-site Base Rate (available for select children's services and crisis- brief for both adult and children.) 1519 $181.16 $139.25 April 1, 2019 $181.16 $139.25
    Health Services (Only for SBIRT under Workers' Compensation) 1588 $181.16 $139.25 April 1, 2019 $181.16 $139.25
    Crisis Intervention 1576 $181.16 $139.25 April 1, 2019 $181.16 $139.25

    *Schedule provides base rates only. For the capital add-on values, refer to the Rate by Provider files on the NYS OMH website.

Resources