Skip to Content

Workers' Compensation Board

Language Assistance: (877) 632-4996 | Language Access Policy

Workers' Compensation Enhanced Ambulatory Patient Group (EAPG)

Ambulatory Surgery Fee Schedule FAQs

  1. What services are covered by the Workers' Compensation (WC) Ambulatory Surgery Fee Schedule? At this time, the WC Ambulatory Surgery Fee Schedule only covers outpatient ambulatory surgery in hospital-based or free standing ambulatory surgery centers. Inpatient stays are reimbursed by APR-DRG methodology.
  2. Does this apply to No Fault? The Board does not oversee No Fault. Any questions regarding No Fault, including payment of Ambulatory Surgery Bills, should be directed to the Department of Financial Services.
  3. Will a new fee schedule be posted or must we calculate payments? An Ambulatory Surgery Fee Schedule will not be posted. Stakeholders may calculate payments either through the use of the 3M Grouper software, or manually.
  4. Is the Board going to replace the 2012 Medical Fee Schedule Manuals? The Ambulatory Surgery Fee Schedule neither impacts nor replaces the 2012 Provider fee schedule.
  5. Has an analysis been done to quantify the overall impact on WC claims? An analysis was performed. The transition to EAPG is expected to result in a slight net increase in payments.
  6. Is the software available? Can billers purchase the software? How much does it cost? The 3M Core Grouper software or cloud based GPCS is available. Any organization that processes healthcare 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 contact information? James Fairs | Account Manager, Population and Payment Solutions
    3M Health Information Systems
    Office: 518 426 4315
    | jfairs@mmm.com | www.3Mhis.com
  8. Does the 3M Core Grouper software calculate inpatient and outpatient bills? The 3M Core Grouper software can be used to calculate APR DRGs for inpatient bills and EAPGs for outpatient bills. It should be noted that the 3M product is not required to make the necessary calculations. Alternate products may be available and the calculations can be done manually as well.
  9. Is there a grace period for stakeholders who haven't purchased the software yet? There is no grace period for stakeholders who have not purchased the software. The software is not required; facility bills can be manually calculated. Facility payment is due within 45 days.
  10. 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 in house per the EAPG methodology. The Medical Directors Office can provide assistance and guidance but since the 3M software is available it is no longer repricing bills.
  11. 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.
  12. Where do I find the rates for my facility? Rates can be found on the Department of Health's APG page under reimbursement requirements: http://www.health.ny.gov/health_care/medicaid/rates/apg/index.htm
  13. Is there a difference in billing for hospital-based vs. free standing ambulatory surgery services? Both hospitals and ambulatory surgery centers would bill using a UB-04. The same base rates are used for services provided in a hospital as well as an ambulatory surgery center. However, the capital add-on values differ for hospitals and ambulatory surgery centers. Additionally:
    • hospitals would bill using rate code 1401,
    • out-of-state hospitals would use rate code 1416,
    • ambulatory surgery center would use rate code 1408.
    • Rate code 1401 Upstate Workers' compensation base rate: $228.62, Capital add-on payment: $108.48
    • Rate code 1401 Downstate Workers' compensation base rate: $295.94, Capital add-on payment: $115.70
    • Rate code 1408 Upstate Workers' compensation base rate: $228.62, Capital add-on payment: $109.90
    • Rate code 1408 Downstate Workers' compensation base rate: $295.94, Capital add-on payment: $81.37
  14. Are rate codes required to be on the bill? The appropriate rate codes can be found on the DOH website. For the time being, code 1401 is for hospital outpatient surgery services and 1408 is for ambulatory surgery centers when using EAPG methodology . The January 2016 release will also include rate code 1416, to be used for ambulatory surgery performed at an out-of-state hospital. Bills submitted without rate codes should not be rejected.

    The Board does not authorize ambulatory surgery centers or hospitals. Any NYS hospital that performs outpatient surgery and/or NYS Dept. of Health 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.
    • Rate code 1401 Upstate Workers' compensation base rate: $228.62, Capital add-on payment: $108.48
    • Rate code 1401 Downstate Workers' compensation base rate: $295.94, Capital add-on payment: $115.70
    • Rate code 1408 Upstate Workers' compensation base rate: $228.62, Capital add-on payment: $109.90
    • Rate code 1408 Downstate Workers' compensation base rate: $295.94, Capital add-on payment: $81.37
  15. Did the Board adopt the Medicaid Never Pay list? The Board adopted the Medicaid Never Pay list.
  16. What form should be submitted for ambulatory surgery bills? Ambulatory surgery procedures should be billed on a UB-04.
  17. Where are the EAPG codes entered on the 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 CPT codes. Bills should not be rejected if the EAPGs codes are not listed.
  18. 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.
  19. Will all services be paid using EAPGs? Are prior year or deleted CPT codes included? New York Workers' Compensation EAPG implementation only covers outpatient ambulatory surgery. EAPGs codes cover all current CPT codes. There is a crosswalk available on the Board's website to assist stakeholders in mapping prior year or deleted CPT codes to current CPT codes.
  20. Does EAPG cover codes not listed in Products of Ambulatory Surgery (PAS)? The EAPG methodology maps appropriate current CPT procedures to ICD-10 codes.
  21. Where is the logic to consolidate edits? The EAPG consolidation logic can be found on the DOH website http://www.health.ny.gov/health_care/medicaid/rates/bundling/
  22. Which NCCI edits are used? Hospital outpatient NCCI edits and Medical Unlikely Edits are used.
  23. Is pre-op testing included in the EAPG? Pre-op testing should be billed using the 2012 Medical Fee Schedule. 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.
  24. Does each facility's Op-Cert number contain their EAPG rate? DOH issues EAPG rates for Medicaid upon request based on a facilities NPI and Op-Cert number. However, payment can be calculated generically without an NPI or Op-Cert 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 ambulatory surgery centers or hospitals. Any NYS hospital that performs outpatient surgery and/or NYS Dept. of Health 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.
    • Rate code 1401 Upstate Workers' compensation base rate: $228.62, Capital add-on payment: $108.48
    • Rate code 1401 Downstate Workers' compensation base rate: $295.94, Capital add-on payment: $115.70
    • Rate code 1408 Upstate Workers' compensation base rate: $228.62, Capital add-on payment: $109.90
    • Rate code 1408 Downstate Workers' compensation base rate: $295.94, Capital add-on payment: $81.37
  25. Why doesn't the 150% increase apply to the capital add-on amount? The capital add-on value is an amount provided by the Department of Health 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 Workers' Compensation specific base rate.
  26. 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 amount is zero. Normally, the capital add-on amount is not zero, but there are a few exceptions where there is no capital add-on for certain services.
  27. 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.
  28. Does claimant gender and birthday affect EAPG assignment? Age and gender do affect some EAPG assignments. In addition, there are some ICD-10 CM diagnosis codes and certain CPT/HCPCS procedure codes that are age and gender sensitive.
  29. How does the Board's Ambulatory Surgery Facility Fee Schedule provide for reimbursement of implants used as part of a surgical procedure? EAPG utilizes a different reimbursement methodology than PAS. Implants are reimbursed, but not as an add-on.

    EAPG payment is based on the severity of an episode of care. The 2015 EAPG fee schedule has a 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.
  30. Are providers required to submit invoices for implant charges for Ambulatory Surgery bills submitted after 10/1/15 under the EAPG methodology? Since reimbursement for implants is included in ambulatory surgery bills submitted under EAPG, invoices for the cost of implants are no longer required. (See question #8)

    Bills that were submitted prior to 10/1/15 and that will be calculated using the PAS methodology will continue to require the submission of a manufacturer's invoice cost.
  31. Do outpatient hospitals and ASCs still bill implants using the unlisted supply code of 99070 under EAPG methodology? ASCs and hospitals bill for implants used in outpatient surgery procedures using the designated HCPCS code for the item(s).
  32. 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.
  33. What is the Board doing to get payers to pay correctly?
    Prior to the October 29th 3M software release, the Board's Medical Director's Office made staff available to calculate EAPG outpatient hospital and facility reimbursement at the request of both payers and providers. Reference documents including helpful links to the Department of Health's APG reference materials are on the EAPG Ambulatory Surgery Fee Schedule page on the Board's website.
  34. When will additional training sessions be held? No additional trainings are scheduled at this time. The presentation is available on the Board's website.
  35. Did the November 13th, December 4th, and December 9th training sessions offer CEU credits? CEU credits were not offered as part of the EAPG training sessions.