Board Bulletins and Subject Numbers

January 22, 2010

The workers' compensation fee schedule for inpatient hospital care automatically tracks New York Medicaid rates, as determined by the New York State Department of Health (DOH), with limited statutory modifications. New York Public Health Law § 2807-c (1)(b-1). As required by statute, the DOH provided the Workers' Compensation Board (Board) with its new reimbursement rates for inpatient hospital care on January 4, 2010. Those new rates are now posted on the Board's website at: http://www.wcb.ny.gov/content/main/hcpp/MedFeeSchedules/medfee.jsp#2009

The rates are based on a new methodology adopted by DOH known as All Patients Refined Diagnosis Related Groups (APR-DRG). The new rates are effective for all discharges between December 1, 2009 and December 31, 2009. There will be new rates for discharges on or after January 1, 2010 posted when we receive them from DOH.

To prepare for transition to this new system, the Board, in conjunction with the DOH and its contractor 3M Health Information Systems, held a webinar in December 2009 regarding the new APR-DRG methodology. You can review the webinar at https://cc.callinfo.com/cc/schedule/display.do?udc=1d4yfkzun38ky

Additional information about the APR-DRG system is also available on the DOH's website at: http://www.health.ny.gov/facilities/hospital/reimbursement/apr-drg/.

Spinal Surgery Hardware Reimbursement

During the webinar, several participants asked about the continued application of WCL § 13(a-1), which provides for the separate reimbursement of implantable hardware and instrumentation costs in addition to the procedure payment in spinal surgeries through March, 31, 2011. The statute identifies the surgeries subject to this special rule by AP-DRG code. The new APR-DRG codes do not directly correspond to existing AP-DRG codes. However, there is very close correlation between the procedures in the covered range of AP-DRGs and those in APR-DRG codes 23 (spinal procedures), 303 and 304 (dorsal and lumbar fusions), 310 (disk excision and compression), and 321 (cervical spinal fusion).

Therefore, the requirement of separate reimbursement of implantable hardware and instrumentation costs will apply to spinal procedures in APR-DRG codes 23, 303, 304, 310, and 321. The Board intends to promulgate regulations that adopt this interpretation.

Application of 45 Day Bill Review Requirement

The new fees go into effect retroactive to December 1, 2009. Several participants in the webinar asked whether there will be relief from the requirement that carriers pay or contest medical bills within 45 days of receipt of the bill. The Board understands the concerns of carriers who have not yet been able to transition to a new APR-DRG-based bill review and payment system. At this time, however, the Board will not establish an exception to the timeliness of payment rule.

Instead, the Board recommends that carriers review and pay hospital bills according to their existing bill review and payment system, even if it is still based on AP-DRGs. Where applicable, they should notify the hospital that the review is based on the previous system and should attempt to reconcile the bill payment to the new reimbursement rates under APR-DRGs as soon as possible. The lack of software to evaluate bills under the APR-DRG system is not a basis to refuse to pay hospital bills. Carriers who are seeking technical assistance regarding the APR-DRG system should consult the DOH website's information at: http://www.health.ny.gov/facilities/hospital/reimbursement/apr-drg/.

Robert E. Beloten
Chair