Claims > Facility Claims Requirements
Ambulatory Patient Group (APG) Rate Codes
EmblemHealth pays claims billed with ambulatory patient group (APG) rate codes (and their corresponding CPT codes) for services covered by APG reimbursement. The APG system is the New York State-mandated payment methodology for most Medicaid outpatient services. APGs will be paid for outpatient clinic, ambulatory surgery and emergency department services when the service is reimbursed at the Medicaid rate. APGs will not be used for services that are carved out of Medicaid managed care.
To facilitate APG claims processing, please:
- Submit APG and non-APG services on separate claims
- Report a value code of 24 and an appropriate rate code
- Report CPT codes for all revenue lines
Claims without proper coding will be returned to you for correction prior to adjudication.
More information on APGs can be found at the New York State Department of Health's website at www.health.state.ny.us/health_care/medicaid/rates/apg/, as well as the DOH's Policy and Billing Guidance Ambulatory Patient Groups (APGs) Provider Manual at www.health.state.ny.us/health_care/medicaid/rates/apg/docs/apg_provider_manual.
For documentation on known APG issues and HIPAA APG requirements, go to eMedNY's website at www.emedny.org/apg_known_issues.pdf and at www.emedny.org/HIPAA/index.html.
"Present on Admission" Indicator for Hospitals
The Deficit Reduction Act of 2005 requires hospitals to report the secondary diagnoses (if present) for Medicare and Medicaid patients. To comply with this government program, EmblemHealth requires a "present on admission" (POA) indicator for the following claims:
- Acute care hospital admissions for Medicare members
- All medical inpatient services
- Substance abuse treatment
- Mental health admissions
Note: Patients considered exempt by Medicare must also have POA indicators noted. If the diagnosis is exempt, enter a value of "1."
A POA indicator is not needed for Medicare member claims in the following hospitals:
- Critical access hospitals
- Inpatient rehabilitation facilities
- Inpatient psychiatric facilities
- Maryland waiver hospitals
- Long term care hospitals
- Cancer hospitals
- Children's hospitals
- Hospitals paid under any type of prospective payment system (PPS) other than the acute care hospital PPS
A POA indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the ICD-9-CM Official Guidelines for Coding and Reporting, by the Centers for Medicare & Medicaid Services [CMS] and the National Center for Health Statistics [DHHS]) and the external cause of injury. CMS does not require a POA indicator for the external cause of injury unless it is being reported as an "other" diagnosis.
If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA indicator would not be reported.
Yes. The condition was present at the time of inpatient admission.
No. The condition was not present at the time of inpatient admission.
Unknown. The documentation is insufficient to determine if the condition was present at the time of inpatient admission.
Clinically undetermined. The provider is unable to clinically determine whether the condition was present at the time of inpatient admission or not.
Unreported/not used, exempt from POA reporting. This code is the equivalent code of a blank on the UB-04. However, it was determined that blanks were undesirable when submitting this data via the 4010A.
Issues related to inconsistent, missing, conflicting or unclear documentation must be resolved by the practitioner.
More information and coding instructions, including the POA Fact Sheet, can be found on the CMS website at www.cms.gov/MLNMattersArticles/downloads/MM5499.pdf and at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/wPOAFactSheet.pdf.
Glossary terms found on this page:
The process by which a claim is paid or denied based on eligibility and contract determination.
Formal acceptance as an inpatient by an institution, hospital or health care facility.
Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
The government agency responsible for administering the Medicare and Medicaid programs.
The US government's principal agency for protecting the health of all Americans and providing essential human services. Also called the Department of Health and Human Services.
Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.
A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.
A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
A federal act that protects people who change jobs, are self-employed or have pre-existing medical conditions. The act standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those offered to employees in large group plans. The act also contains provisions to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status and protects the confidentiality of protected health information of members. Also known as the Health Insurance Portability and Accountability Act.
An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:
- Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
- Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
- Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
- Maintains medical records for all patients
- Has a requirement that every patient be under the care of a member of the medical staff
- Provides 24-hour patient services
- Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements
Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.
The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called NYSDOH.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
The use of one or more drugs for purposes other than those for which they are prescribed or recommended.