NYS Medicaid APG Readiness for Border States

In December of 2008, the New York State Medicaid program began the transition to the Ambulatory Patient Groups (APG) prospective reimbursement methodology to pay providers for outpatient services. Starting on July 1, 2009, New York State will utilize the APG system to pay out-of-state providers who render outpatient services to NYS Medicaid beneficiaries. As a hospital in a neighboring state in close proximity to New York which may be treating a significant number of NYS Medicaid beneficiaries, be aware of how Provider Consulting Solutions, Inc (PCS) can assist you and your staff to ensure readiness for this change in reimbursement methodology.

PCS is a full service healthcare management consulting firm with particular expertise in navigating intricate Medicaid regulations. We are uniquely qualified to assist hospitals with preparing for the transition to APGs. Our team is comprised of clinical and reimbursement professionals who spend 100% of their time assisting healthcare providers with the complicated environment of inpatient and outpatient coding and billing. PCS has a strong presence in healthcare consulting with a reputation for delivering high quality services across a broad range of issues impacting health care providers. In addition to experience gained from working with literally hundreds of hospitals on DRG, charge description master (CDM), APC-related issues and assisting numerous hospitals and their legal counsel with specific compliance initiatives (including RAC) associated with accurate coding of inpatient and outpatient services, PCS staff has provided education throughout NY State on the APG system.

PCS offers a variety of services related to APG preparedness. Depending on the specific needs of a hospital, one or more of these services may be appropriate. Services offered include:

Staff Education

The transition to APGs represents a significant change in Medicaid outpatient reimbursement and will affect many people in many departments. The payment of APGs is driven by HCPCS codes (as used by the Medicare APC methodology) and/or ICD-9 diagnoses code. Hospital staff and leadership need to understand the APG system in order to effectively prepare for implementation; they should understand the purpose of APGs, the basics of how APGs are paid and the importance of accurate documentation and coding of records for appropriate Medicaid APG reimbursement.

PCS can deliver APG education through a variety of means including classroom education, internet web-casts and DVDs. PCS will work with your hospital to develop the most efficient and effective delivery system(s) needed to cover the education of the hospitals staff.

Diagnostic Assessment

Medicaid Outpatient Record Audit

PCS staff can review Medicaid records from the emergency department, general clinic, specialty clinics and ambulatory surgery department for appropriate coding and charging of services. PCS will review the records to determine if the documentation, charging, coding and billing are accurate and complete. The object of the review is to determine the appropriateness of the coding as it relates to the documentation included in the patients charts.

At the conclusion of the review PCS will provide coding worksheets summarizing the suggestions and changes, as well as the expected APG reimbursement impact due to the suggested revisions.

PCS will prepare a summary report identifying the issues found related to the documentation, charge capture, coding and charging processes, and/or APG assignment. The report will also include suggestions for operational changes and/or other corrective actions, as needed to prepare the Hospital for appropriate and efficient Medicaid APG coding and billing.

Charge Description Master Desk Review

PCS will perform a desk review of the hospitals CDM to assess its completeness and accuracy for proper billing under the NYS Medicaid APG system. PCSs desk review is focused on Medicaid HCPCS-driven services. Primary elements of the desk review include the following

• Identification of Medicaid-reimbursed HCPCS codes not currently on the CDM
• Identification of obsolete and/or modified HCPCS codes with recommended replacement HCPCS as appropriate
• Identification of unlisted codes for review and replacement with a more specific code if available
• Analysis of modifier reporting on the CDM

The CDM desk review will provide your hospital with a useful assessment of the completeness and accuracy of its CDM and will identify specific departments where a follow-up comprehensive CDM analysis and review may be appropriate.

Potential Follow-up Initiatives

Comprehensive Charge Description Master Review

PCSs comprehensive CDM review entails significant interaction with clinicians to fully understand the clinical aspects of the services being charged and coded. The comprehensive review can frequently identify the root source of coding errors and omissions.

Review of Coding and Charge Capture Process

PCS can review your hospitals coding and charge capture processes (in close consultation with hospital management and staff knowledgeable in ED, clinic, and ambulatory surgery coding and charge capture) to determine if they are efficient and will lead to proper coding and billing under Medicaid APGs.

PCS would welcome the opportunity to assist your hospital in confronting the challenges presented by the APG methodology.