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.gov.

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?

   3M Website: www.3M.com/his

   3M Phone: (800) 367-2447

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) page 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 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.

26. Has NYS WCB adopted the NYS DOH regions?

    Yes, NYS WCB will use the Downstate and Upstate Regions as defined by NYS DOH.

    The Downstate Region will consist of the five counties comprising New York City, and the counties of Nassau, Suffolk, Westchester, Rockland, Orange, Putnam, and Dutchess. The Upstate Region will consist of all other counties in New York State.

2021 EAPG Fee Increases

1. Are the codes listed all-inclusive or are additional fees for materials or services permitted?

   The prices are all-inclusive in the single code and no additional fees may be charged for the listed procedure Final reimbursement will include the Capital Add On payment.

2. What if a procedure needs to be revised or repeated?

   A prior authorization request must be submitted and approved in order to revise or repeat a procedure, even if the original procedure was authorized under the medical treatment guidelines.

3. Are implants covered by these updated fees?

   Implants are included in the new prices and may not be billed separately.

4. Are facility fees (Capital Add On payments) additional fees?

   Facility fees are allowed as additional fees.

5. Can separate procedures be billed separately?

   Two separate procedures for two distinct body part injuries (for example, two distinct joints, not two distinct bones within the same joint) may be billed separately. If two separate procedures are performed on the same day, only a single facility fee may be billed for both procedures.

6. Would additional procedure codes and add-on codes be allowed?

   Medically necessary and appropriate procedures performed during the same surgical session will be reimbursed in accordance with EAPG methodology.

7. How are bilateral procedures for the designated codes reimbursed?

   Reimbursement for the designated codes billed bilaterally would be 100% of the listed price for each procedure.

8. Will the designated codes still be processed through the 3M Grouper?

   Yes, the 3M Grouper software will be updated to reflect these changes. Final calculations will include the Capital Add On payment for the facility.

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 Services.

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?

   3M Website: www.3M.com/his

   3M Phone: (800) 367-2447

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) page 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 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.

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.

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) 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.