N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-4.9

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

Section 86-4.9 - Units of service

(a) The unit of service used to establish rates of payment shall be the threshold visit, except for dialysis, abortion, sterilization services and free-standing ambulatory surgery, for which rates of payment shall be established for each procedure. For methadone maintenance treatment services, the rate of payment shall be established on a fixed weekly basis per recipient.

(b) A threshold visit, including all part-time clinic visits, shall occur each time a patient crosses the threshold of a facility to receive medical care without regard to the number of services provided during that visit. Only one threshold visit per patient per day shall be allowable for reimbursement purposes, except for transfusion services to hemophiliacs, in which case each transfusion visit shall constitute an allowable threshold visit.

(c) The following shall not constitute threshold visits within the meaning of subdivisions (a) and (b) of this section:

(1) visits solely for the purpose of receiving ordered ambulatory services;

(2) visits solely for the purpose of receiving pharmacy services;

(3) visits solely for the purpose of receiving nutrition services;

(4) visits solely for the purpose of receiving respiratory therapy;

(5) visits solely for the purpose of receiving recreation therapy;

(6) visits solely for the purpose of receiving medical social services, except for clinical social worker psychotherapy services as defined in subdivision (g) of this section;

(7) visits solely for the purpose of receiving group services, except for clinical group psychotherapy services in accordance with the provisions of subdivision (h) of this section;

(8) offsite services, defined as medical services provided by a facility's clinic staff at locations other than those operated by and under the licensure of the facility, or visits related to the provision of such offsite services, except in accordance with the provisions of subdivision (i) of this section.

(d) A procedure shall include the total service, including the initial visit, preparatory visits, the actual procedure and follow-up visits related to the procedure. All visits related to a procedure, regardless of number, shall be part of one procedure and shall not be reported as a threshold visit.

(e) Rates for separate components of a procedure may be established when patients are unable to utilize all of the services covered by a procedure rate. No separate component rates shall be established unless the facility includes in its annual financial and statistical reports the statistical and cost apportionments necessary to determine the component rates.

(f) Ordered ambulatory services may be covered and reimbursed on a fee-for-service basis in accordance with the State medical fee schedule. Ordered ambulatory services are specified services provided to nonregistered clinic patients at the facility, upon the order and referral of a physician, physician's assistant, dentist or podiatrist who is not employed by or under contract with the clinic, to test, diagnose or treat the patient. Ordered ambulatory services include laboratory services, diagnostic radiology services, pharmacy services, ultrasound services, rehabilitation therapy, diagnostic services and psychological evaluation services.

(g) For purposes of this section, clinical social worker psychotherapy services are defined as individual psychotherapy services provided in a federally qualified health center, by a licensed clinical social worker or by a licensed master social worker who is working in a clinic under qualifying supervision in pursuit of licensed clinical social worker status by the New York State Education Department.

(h) Clinical group psychotherapy services provided in a federally qualified health center, (FQHC) are defined as services performed by a clinician qualified as in subdivision (g) of this section, or by a licensed psychiatrist or psychologist to groups of patients ranging in size from two to eight patients. Clinical group psychotherapy shall not include case management services. Reimbursement for these services shall be made on the basis of a FQHC group rate which will be calculated by the department for this specific purpose, payable for each individual up to the limits set forth herein, using elements of the resource based relative value system (RBRVS) promulgated by the Centers for Medicare and Medicaid Services (CMS), and approved by the State Division of Budget.

(i) Federally qualified health centers will be reimbursed for the provision of offsite primary care services to existing FQHC patients in need of professional services available at the FQHC, but, due to the individual's medical condition, is unable to receive the services on the premises of the center.

(1) FQHC offsite services must:

(i) consist of services normally rendered at the FQHC site;

(ii) be rendered to an FQHC patient with a pre-existing relationship with the FQHC (i.e., the patient was previously registered as a patient with the FQHC) in order to allow the FQHC to render continuous care when their patient is too ill to receive on-site services, and only to patients expected to recover and return to become an on-site patient again. Off-site services may not be billed for patients whose health status is expected to permanently preclude return to on-site status;

(iii) be rendered only for the duration of the limiting illness, with the intent that the patient return to regular treatment as an on-site patient as soon as their medical condition allows;

(iv) be an individual medical service rendered to an FQHC patient by a physician, physician assistant, midwife or nurse practitioner;

(v) not be rendered in a nursing facility or long-term care facility, to any patient expected to remain a patient in that facility or at that level of care;

(vi) not be billed in conjunction with any other professional fee for that service, or on the same day as a threshold visit.

(2) Reimbursement for these services shall be made on the basis of an FQHC offsite professional rate, which will be calculated by the department using elements of the resource based relative value system (RBRVS) promulgated by the Centers for Medicare and Medicaid Services (CMS) and approved by the State Division of Budget.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-4.9