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Oral-Only Phosphate Binders reimbursement- MVP Medicaid, HARP plans

Posted on January 19, 2026 by KR2Medical Billing

To align with NYS Medicaid ESRD reimbursement for oral-only phosphate binders- MVP will include the reimbursement in the newly aligned Dialysis center APG reimbursement. Effective for any DOS 1/1/2026.

Higlights:

Oral only Phosphate binders for ESRD members no longer will be dispensed through the pharmacy NYRx benefit
The Phosphate binders will be dispensed by the dialysis center
Reimbursement- no separate reimbursement will be made for oral only phosphate binders instead it is included in the new APG dialysis rate
Dialysis centers should not bill a separate claim for these phosphate binders (ESRD patients)
Oral only phosphate binders affected by this change: sevelamer carbonate, lanthanum carbonate, sucroferric oxyhydroxide, and ferric citrate.

NYS APG rate:

The FFS APG weight for APG 168 (dialysis) has increased from 1.3651 to 1.5302.

For the NYS Medicaid announcement click here .

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Understanding Nursing Home vs PDN Coding-NYS

Posted on January 15, 2026 by KR2Medical Billing

In order for us to understand the coding difference between the nursing home visit codes and PDN (private duty nursing) codes, we need to go back to the basics.

Definitions:

Nursing Home services/visits- the necessary intermittent or part-time nursing care provided for a patient in the patient’s home or home substitute on a per visit basis. These services are usually no more than 2 hours per day and are performed by the Certified Home Health Agency.

Private Duty Nursing services/visits- nursing services that are one on one more personal level, for medical fragile members, that are performed on continuous basis. The purpose of Private Duty Nursing is to assist the caregiver/family members to help the member to remain safely at home. There is a separate code set for PDN services and a corresponding fee schedule.

Reimbursement:

Nursing Home Visits: are reimbursed in the increments of 15 min

PDN services/visits: are reimbursed by hour.

Exception: the following 2 code are reimbursed per diem because they represent the 13-hour shift

T1030- nursing care by RN, per diem, at home- 13 hour shirt

T1031- nursing care by LPN, per diem, at home- 13-hour shift

Coding–

I. Nursing Home Visits/Services:

a. T1002- RN services, up to 15 min

b. T1003- LPN services, up to 15 min

II. PDN services/visits:

a. S9123- RN services, per hour

b. S9124- LPN services, per hour

Please note that when you are billing the T codes you cannot bill them with the “other nursing codes” , listed below, or when the codes listed below better represent the nursing services that are authorized, performed.

Other Nursing Codes:

Need more information about NYS Medicaid Home and Community LTC codes: please visit here

PDN services fee schedule, here.

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NYS Medicaid OBGYN CPT II codes reporting requirement

Posted on January 8, 2026January 8, 2026 by KR2Medical Billing

If you are a provider in NY and accept Managed Medicaid or Fee-for-service Medicaid plan types, then this blog post post is for you!

For any DOS (for deliveries on July 1, 2024) and thereafter, the OBGYN providers billing bundled/global OBGYN codes, are also required to bill the following CPT II reporting codes.

Global OBGYN codes:

CPT category II codes:

Reimbursement- none

These CPT category II codes are only for reporting purposes.

For MCO- Managed Medicaid Members – if amount is needed in order to accept/generate a claim provider could put a charge of $0.01.

Claim submission:

Providers need to submit a separate claim with CPT category II codes at the time that the member comes in for the prenatal/postnatal visit.

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