N.Y. Comp. Codes R. & Regs. Tit. 10 § 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.
Notes
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No prior version found.