N.Y. Comp. Codes R. & Regs. tit. 10 § 85.6

Current through Register Vol. 46, No. 50, December 11, 2024

Section 85.6 - Admissions and hospital stays

(a) Inpatient hospital admissions which do not require a determination of benefit coverability under sections 85.1 through 85.4 of this Part and except for admissions under subdivision (f) of this section shall be deemed a covered benefit under medical assistance for the needy as provided in section 365-a (2)(b) of the Social Services Law for the first three days of inpatient hospital care. To be a covered benefit after the third day of inpatient hospital care, there shall be a determination of benefit coverability prior to the end of the third day by a person designated by the Commissioner of Health. Such determination shall be for a specified period of time not to exceed the 50th percentile of length of stay norms for comparable patients which have been authorized by the Commissioner of Health or the 20th day of stay, whichever is less. If the stay is for rehabilitation of physical disability as described in subdivision (a) of section 85.5 of this Part, such specified period of time shall not exceed the 40th day of stay. Determination of coverability shall be based upon existence of medical conditions which can be treated only on an inpatient hospital basis, as documented in the patient's medical record. Subsequent to this initial determination of coverability, extensions of benefit coverability shall be subject to length of stay limitations of sections 85.5 and 85.7 of this Part.

(b) A determination of benefit coverability under this section shall be made by a designated physician or nonphysician under a designated physician's supervision. A determination of noncoverability shall be made only by a designated physician. If such determination of noncoverability is made, any inpatient hospital care, supplies or services provided beyond three days shall not be a covered benefit under medical assistance for the needy.

(c) Notice of determination shall be given to the patient's physician, the hospital administrator and, if there is a determination of noncoverability, to the patient.

(d) The patient's physician or hospital administrator may, within three days of the date of such notification, appeal a determination of noncoverability in writing to the physician or physicians designated by the commissioner for such purpose. Notification of the decision on appeal shall be given to the patient's physician, the hospital administrator and the patient. If determination of noncoverability is affirmed on appeal, any inpatient hospital care, supplies or services provided beyond three days shall not be a covered benefit under medical assistance for the needy.

(e) If the person designated by the Commissioner of Health decides in the course of making determinations of coverability under this section or it is determined from other sources that a physician, physicians or the hospital are admitting patients for medical conditions which can be treated on other than an inpatient hospital basis, the designated person shall give written notification to the physician(s) and the hospital that if such admissions continue, the initial three-day period of stay will no longer be deemed a covered benefit. If patients are thereafter admitted for medical conditions which can be treated on other than an inpatient hospital basis, the designated person shall notify the physician(s) and the hospital that to be a covered benefit, the first three days of inpatient stay will be subject to a determination of coverability. Such determination of coverability shall be made prior to the end of the third day of inpatient hospital stay in accordance with the procedures in subdivisions (a) through (d) of this section. If there is a determination of noncoverability, any inpatient hospital care, supplies or services provided shall not be a covered benefit under medical assistance for the needy.

(f)

(1) During such period of time as sections 85.2 and 85.3 of this Part do not apply, all surgery, other than emergency or urgent surgery, within "medical assistance" as defined in section 365-a of the Social Services Law, shall require a determination of coverability by a person designated by the Commissioner of Health prior to admission. A determination of coverability shall be based on a finding that the proposed surgery can be performed properly only on an inpatient hospital basis.

(2) A determination of coverability shall be for a specified period of time not to exceed the 50th percentile of length of stay norms for comparable patients which have been authorized by the commissioner or the 20th day of stay, whichever is less. If the stay is for rehabilitation of physical disability as described in section 85.5(a) of this Part, such specified period of time shall not exceed the 40th day of stay. Subsequent to this initial determination of coverability, extensions of benefit coverability shall be subject to length of stay limitations of sections 85.5 and 85.7 of this Part.

(3) The required determination of coverability shall be initiated by written request from the proposing surgeon, with information adequate for making the determination. A determination of coverability shall be made by a designated physician or nonphysician under supervision of a designated physician. A determination of noncoverability shall be made only by a physician.

(4) Notice of determination shall be given to the proposing surgeon who shall, if coverability is determined, incorporate such notice in the hospital record at admission.

(5) The proposing surgeon may appeal any determination of noncoverability to a physician or physicians designated by the Commissioner of Health for such purpose. Notification of decision on appeal shall be given to the proposing surgeon who shall incorporate any notice of determination of coverability in the hospital record at admission.

(6) Admissions and hospital stays solely for the purpose of performing any procedure which may be performed on an outpatient basis, as defined in paragraph (7) of this subdivision, shall not be included as inpatient care in a hospital or care in a hospital-based ambulatory surgery service or a free-standing ambulatory surgery center for purposes of coverability of benefits except that a determination of coverability may be made by a person designated by the Commissioner of Health when the medical condition of the individual patient requires that such procedure be performed on an inpatient basis in a hospital or as care in a hospital-based ambulatory surgery service or a free-standing ambulatory surgery center. For inpatient hospital, hospital-based ambulatory surgery service and free-standing ambulatory surgery center admissions for certain surgical procedures, as defined in paragraph (7) of this subdivision there shall be a determination prior to admission of the specified period of coverability as provided for in this subdivision, except for emergency admissions for which the determination of the period of coverability shall be made as soon after admission as feasible.

(7) A procedure which may be performed on an outpatient basis ("outpatient procedure"), is a diagnostic test or treatment, including certain surgical procedures, that carries a low patient risk, requires minimal preand post-procedure observation and treatment, is not likely to be time consuming or followed by complications, and is not associated with a condition which would require hospitalization. Column (1) lists "The International Classification of Diseases, 9th Revision, Clinical Modification" (ICD-9 CM) procedure codes for outpatient surgery and column (2) below lists the outpatient surgical (ICD-9-CM) procedure names. Such outpatient procedures include, but are not limited to, the following:

(1)	(2)
ICD-9-CM Procedure Code	ICD-9-CM Procedure Name
(i) 3.31	Spinal tap
(ii) 8.09	Other eyelid incision
(iii) 8.11	Eyelid biopsy
(iv) 8.20	Removal of lesion of eyelid, NOS
(v) 8.21	Excision of chalazion
(vi) 8.22	Excision of other minor lesion of eyelid
(vii) 8.41	Repair entrop/ectro-thermocauterization
(viii) 8.42	Repair entrop/ectro. by suture tech.
(ix) 8.52	Blepharorrhaphy
(x) 18.09	Other incision of external ear
(xi) 18.21	Excision of preauricular sinus
(xii) 18.29	Excis./destruct. of other lesion ext. ear
(xiii) 20.09	Other myringotomy
(xiv) 21.21	Rhinoscopy
(xv) 21.22	Biopsy of the nose
(xvi) 21.30	Excis./destruct. of lesion-nose, NOS
(xvii) 21.31	Local excsn./destruct.-intranasal lesion
(xviii) 21.32	Local excsn./destruct.-other lesion of nose
(xix) 21.61	Turbinectomy by diathermy or cryosur
(xx) 21.69	Other Turbinectomy
(xxi) 23.01	Forceps extraction of deciduous tooth
(xxii) 23.09	Forceps extraction of other tooth
(xxiii) 23.11	Surgical removal of residual root
(xxiv) 23.19	Other surgical extraction of tooth
(xxv) 23.20	Restoration of tooth by filling
(xxvi) 23.30	Restoration of tooth by inlay
(xxvii) 23.41	Application of crown
(xxviii) 23.42	Insertion of fixed bridge
(xxix) 23.43	Insertion of removable bridge
(xxx) 23.49	Other dental restoration
(xxxi) 23.50	Implantation of tooth
(xxxii) 23.60	Prosthetic dental implant
(xxxiii) 23.70	Root canal, NOS
(xxxiv) 23.71	Root canal therapy with irrigation
(xxxv) 23.72	Root canal therapy with apicoectomy
(xxxvi) 23.73	Apicoectomy
(xxxvii) 24.00	Incision of gum or alveolar bone
(xxxviii) 24.11	Biopsy of gum
(xxxix) 24.12	Biopsy of alveolus
(xl) 24.19	Other diag. proc. on teeth, gums
(xli) 24.20	Gingivoplasty
(xlii) 24.31	Excision of lesion of tissue of gum
(xliii) 24.32	Suture of laceration of gum
(xliv) 24.39	Other operations on gum
(xlv) 24.40	Excision of dental lesion of jaw
(xlvi) 24.50	Alveoloplasty
(xlvii) 24.60	Exposure of tooth
(xlviii) 24.70	Application of orthodontic appliance
(xlix) 24.80	Other orthodontic operation
(l) 24.91	Extension or deepening of buc. sulcus
(li) 24.99	Other dental operations
(lii) 25.02	Open biopsy of tongue wedge biopsy
(liii) 25.10	Excisn./destuctn lesion/tissue tongue
(liv) 27.43	Other excision of lesion/tissue lip
(lv) 27.49	Other excision of mouth
(lvi) 27.59	Other plastic repair of mouth
(lvii) 31.42	Laryngoscopy and other tracheoscopy
(lviii) 45.24	Flexible sigmoidoscopy
(lix) 48.23	Rigid Proctosigmoidoscopy
(lx) 48.25	Open biopsy of rectum
(lxi) 49.23	Anal biopsy
(lxii) 49.30	Loc. excsn./dest. oth. lesion/tissue of anus
(lxiii) 49.45	Hemorrhoid ligation
(lxiv) 49.47	Evacuation of thrombosed hemorrhoid
(lxv) 56.91	Ureteral meatus dilation
(lxvi) 57.19	Other cystostomy
(lxvii) 57.32	Other cystoscopy
(lxviii) 57.33	Closed (transur) biopsy of bladder
(lxix) 57.94	Insertion of indwelling urinary cath
(lxx) 57.95	Replacement-indwelling urinary cath
(lxxi) 58.10	Urethral meatotomy
(lxxii) 59.80	Urethral catheterization
(lxxiii) 83.21	Biopsy of soft tissue
(lxxiv) 86.04	Other incsn w/drainage of skin/ subcu. tissue
(lxxv) 86.11	Biopsy of skin & subcutaneous tissue
(lxxvi) 86.22	Excision debrid of wound infection or burn
(lxxvii) 86.23	Removal of nail, nailbed, nail fold
(lxxviii) 86.25	Dermabrasion
(lxxix) 86.59	Suture skin/subcut. tissue of other sites
(lxxx) 88.66	Phlebography-femoral, other lower extrm vein c. material
(lxxxi) 89.26	Gynecological examination
(lxxxii) 97.71	Remove intrauterine contraceptive device

(8) Admissions and hospital stays solely for the purpose of performing any procedure which may be performed on an ambulatory surgery basis as defined in paragraph (9) of this subdivision, shall not be included as inpatient care in a hospital for purposes of coverability of benefits except that a determination of coverability may be made by a person designated by the Commissioner of Health when the medical condition of the individual patient requires that such procedure be performed on an inpatient basis in a hospital. For inpatient hospital admissions for procedures listed in paragraph (9) of this subdivision, there shall be a determination prior to admission of the specified period of coverability as provided for in this subdivision, except for emergency admissions for which the determination of the period of coverability shall be made as soon after admission as feasible.

(9) A procedure which may be performed on an ambulatory surgery basis ("ambulatory surgery procedure"), is a diagnostic test, treatment, or procedure which shall be performed for safety reasons in an operating room on anesthetized patients requiring a stay of less than 24 hours' duration. These procedures do not include outpatient office or outpatient treatment room procedures as defined in and covered by paragraph (7) of this subdivision. Column (1) below lists the "The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure names for ambulatory surgical procedures and Column (2) lists the ICD-9-CM procedure codes for ambulatory surgical procedures for which prior approval is necessary for inpatient hospital admission, except for emergency admissions for which the determination of the period of coverability shall be made as soon after admission as feasible. Such ambulatory surgery procedures include, but are not limited to the following:

(1)	(2)
ICD-9-CM Procedure Names	ICD-9-CM Procedure Codes
(i)	spinal tap	03.31
(ii)	other excision or avulsion of cranial and peripheral nerves	04.07
(iii)	release of carpal tunnel	04.43
(iv)	other peripheral nerve or ganglion decompression or lysis of adhesion	04.49
(v)	excision of pterygium	11.39
(vi)	intracapsular extraction of lens by temporal inferior route	13.11
(vii)	other intracapsular extraction of lens	13.19
(viii)	extracapsular extraction of lens by simple aspiration (and irrig.) technique	13.3
(ix)	extracapsular extraction of lens by temporal inferior route	13.51
(x)	other extracapsular extraction of lens	13.59
(xi)	insertion of pseudophakos, NOS	13.70
(xii)	insertion of intraocular lens prosthesis at cataract extraction, 1-stage	13.71
(xiii)	secondary insertion of intraocular lens prosthesis	13.72
(xiv)	recession of one extraocular muscle	15.11
(xv)	advancement of one extraocular muscle	15.12
(xvi)	resection of one extraocular muscle	15.13
(xvii)	other operation on one extraocular muscle involving temporary detachment from globe	15.19
(xviii)	lengthening procedure on one extraocular muscle	15.21
(xvix)	shortening procedure on one extraocular muscle	15.22
(xx)	other operations on one extraocular muscle	15.29
(xxi)	operations on two or more extraocular muscles involving temporary detachment from globe, one or both eyes	15.3
(xxii)	excision or destruction of other lesion of ext. ear	18.29
(xxiii)	myringotomy with insertion of tube	20.01
(xxiv)	other myringotomy	20.09
(xxv)	submucous resection of nasal septem	21.5
(xxvi)	closed reduction of nasal fracture	21.71
(xxvii)	revision rhinoplasty	21.84
(xxviii)	other rhinoplasty	21.87
(xxix)	other septoplasty	21.88
(xxx)	other excision or destruction of lesion or tissue of larynx	30.09
(xxxi)	laryngoscopy and other tracheoscopy	31.42
(xxxii)	biopsy of larynx	31.43
(xxxiii)	bronchoscopy through artificial stoma	33.21
(xxxiv)	fiber-optic bronchoscopy	33.22
(xxxv)	other bronchoscopy	33.23
(xxxvi)	biopsy of lymphatic structure	40.11
(xxxvii)	simple excision of other lymphatic structure	40.29
(xxxviii)	biopsy of bone marrow	41.31
(xxxix)	esophagoscopy through artificial stoma	42.22
(xl)	other esophagoscopy	42.23
(xli)	biopsy of esophagus	42.24
(xlii)	gastroscopy through artificial stoma	44.12
(xliii)	other gastroscopy	44.13
(xliv)	other endoscopy of small intestine	45.13
(xlv)	flexible fiberoptic colonoscopy	45.23
(xlvi)	other endoscopy of large intestine	45.24
(xlvii)	local excision of rectal lesion or tissue	48.35
(xlviii)	incision or excision of perianal tissue	49.01
(xlix)	local excision or destruction of other lesion or tissue of anus	49.3
(l)	other procedures on hemorrhoids	49.49
(li)	laparoscopy	54.21
(lii)	other cystoscopy	57.32
(liii)	urethral meatotomy	58.1
(liv)	release of urethral stricture	58.5
(lv)	dilation of urethra	58.6
(lvi)	bilateral endoscopic ligation and crushing of fallopian tubes	66.21
(lvii)	bilateral endoscopic ligation and division of fallopian tubes	66.22
(lviii)	other bilateral endoscopic c destruction or occulsion of fallopian tubes	66.29
(lix)	other cervical biopsy	67.12
(lx)	dilation and curettage for termination of pregnancy	69.01
(lxi)	other dilation and curettage	69.09
(lxii)	aspiration curettage of uterus for termination of pregnancy	69.51
(lxiii)	other aspiration curettage of uterus	69.59
(lxiv)	marsupialization of Bartholin's gland (cyst)	71.23
(lxv)	other bunionectomy	77.59
(lxvi)	removal of internal fixation device	78.6
(lxvii)	arthroscopy (knee)	80.26
(lxviii)	excision of lesion of tendon sheath of hand	82.21
(lxix)	excision of lesion of other soft tissue	83.39
(lxx)	other biopsy of breast	85.12
(lxxi)	local excision of lesion of breast	85.21
(lxxii)	incision w/removal of foreign body from skin and subcutaneous tissue	86.05
(lxxiii)	application of other cast	93.53

(10) Nothing contained in either paragraph (8) or (9) of this subdivision shall prevent any of the procedures listed in, or otherwise covered by, paragraph (9) of this subdivision from being performed on an outpatient basis.

(g) Inpatient hospital care, services and supplies for admissions beginning on a Friday or Saturday shall include as a covered benefit under medical assistance for the needy only those inpatient days beginning with and following the Sunday after such admission unless a person designated by the Commissioner of Health makes a determination of coverability for such Friday or Saturday while making the determinations required in subdivision (a) of this section and section 85.7 of this Part. A determination of coverability shall be based upon a finding that:

(1) such care, services and supplies commencing with a Friday or Saturday admission are furnished for a medical emergency;

(2) such care, services and supplies commencing with a Friday or Saturday admission are required because of the necessity of emergency or urgent surgery for the alleviation of severe pain or the necessity for immediate diagnosis or treatment of conditions which threaten disability or death if not promptly diagnosed or treated; or

(3) the care, services and supplies commencing with a Friday or Saturday admission are for preoperative care for surgery which has been determined to be a covered benefit under section 85.4 of this Part.

(h) Inpatient days beginning on a Friday or Saturday shall not be subject to the limitations of subdivision (g) of this section in hospitals determined by the commissioner or his designee to be rendering full service on a seven-day-a-week basis. A determination of "full service" shall be made after taking into consideration such factors as the routine availability and use of operating room services, diagnostic services and consultants, laboratory services, radiological services, pharmacy services, staff patterns consistent with full services and such other factors as the commissioner or his designee deems necessary and appropriate.

(i) A determination of coverability of admissions to general hospitals for psychiatric care for persons 16 years of age and older requires that the following shall be met:

(1) The patient's hospital medical record shall contain one or more of the following as documentation for the necessity for admission:

(i) evidence of behavior or thought by the patient, described in the patient's medical record, that is likely to lead to consequences which are a significant danger to the patient or others;

(ii) evidence of deviant behavior exhibited by the patient and described in the patient's medical record, which is no longer tolerable to the patient or to society and is likely to be ameliorated by treatment at this level of care;

(iii) the finding that ambulatory treatment has been unsuccessful in halting or reversing the course of the mental illness, and that inpatient treatment at this level of care is needed in order to prevent or manage behavior or thought described in subparagraph (i) or (ii) of this paragraph;

(iv) the finding that the patient requires a type of therapy which cannot be initiated or continued unless in a supervised setting at this level of care; or

(v) the finding that the patient has a condition other than mental disorder which requires hospital care, but psychological components cannot be handled as well on other units.

(2) A specific treatment plan shall be developed and shall have been implemented within three days following admission.

(3) The patient's response to treatment must be observed and shall be recorded in the patient's medical record.

(4) An anticipated discharge plan shall be developed by the medical staff and shall be recorded in the patient's medical record no later than the fifth day following admission.

(5) A review of the necessity for continued stay shall be carried out in accordance with the provisions of subdivision (b) of section 85.5 of this Part. The patient's hospital medical record shall contain one or more of the following as documentation for the necessity for continued hospital stay:

(i) evidence that there is an immediate physical danger to the patient or others and this level of care is appropriate;

(ii) evidence that the magnitude of the abnormal behavior of the patient remains intolerable to the patient or society, and clinical evidence recorded in the medical chart justifies an extension of stay at this level of care under treatment;

(iii) a finding that if the patient were to be discharged, subparagraph (i) or (ii) of this paragraph; would be likely to recur soon and continued hospitalization would be likely to prevent this. The medical record must document the reason why it is believed likely to recur soon and why continued hospitalization would be likely to prevent the recurrence;

(iv) a finding that the patient's care requires the use and regulation of a specific modality, but the patient lacks motivation and refuses, or is unable, to cooperate under a program of care at another level;

(v) evidence suggests that the patient can improve sufficiently to be treated in an ambulatory setting or other level of care only after additional hospitalization because a major revision of treatment plan has occurred such as (a) change in treatment regimen or (b) patient relapsed unexpectedly; or

(vi) a condition other than mental disorder requires this level of care, but psychological component cannot be handled as well on other services.

N.Y. Comp. Codes R. & Regs. Tit. 10 § 85.6