EAPGS - Washington State Hospital Association

Report
3M Health Information Systems
3M™ Ambulatory Patient Grouping System (EAPGs)
Innovating
the Language
of Health
Washington State Hospital Association Feb 26, 2013
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Agenda
 Introductions
 3M role
 Rationale for EAPG
 EAPGs compared to DRG, APC, APG
 EAPG Grouping Features
 EAPG Reimbursement Features
 Service mix index
 Questions and discussion
2
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3M’s Role
 3M HIS specializes in classification systems (groupers) using
coded claims data for health data analysis and payment
 Provider market focus: the clinical record
― Creating (dictation/transcription) and managing it (document
management and abstracting)
― Coding, coding compliance, managing coding process
― Grouping and reimbursement for managing expected
reimbursement
 Payer market focus: help payers bend the cost curve by deploying
groupers for payment and for quality-based payment incentives
3
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3M’s Role with Payment Initiatives
We:
• Create payment weights
• Create payment policy “levers” (outlier thresholds, policy
adjustors (e.g. DSH)
• Provide instructions and support
• Share information about what other states have done
• Create state-specific grouper and payment formula
We do not:
• Require the use of 3M weights
• “Pull the levers”
4
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More on 3M’s Role with Payment Initiatives
(Cont.)
 Grouper Logic is transparent
 Availability of EAPG Definitions Manual to all at N/C
 Provider Education involving WSHA, WHA, 3M
5
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Rationale for Use of EAPG for Payment
 Payers can best understand and manage outpatient costs by
implementing an outpatient prospective payment system (OPPS).
There are only two OPPS available: APCs and EAPGs
 EAPGs are superior to APCs especially for Medicaid programs:
• Designed for a all-patient rather than for just a Medicare population
• Cover all outpatient services rather than aligning with Medicare
payment policy that uses fee schedules for certain services (e.g.,
therapies, clinical labs, chemotherapy drugs )
• Classify medical outpatient visits based on diagnoses-not E&M codes
matching payment to need and permitting service site neutrality of
payment
• Bundling features create incentives for efficiency
6
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EAPGs In Use Today
7
 OK BC/BS (2009)
 NY Medicaid (2010)
 VA Medicaid - ASCs (2010)
 IA BC/BS (2010)
 SD BC/BS (2010)
Announced:
 VA Medicaid – Hospitals (2013)
 IL Medicaid (2013)
 WI Medicaid (2013)
 MN BC/BS (2013)
In Consideration for 2013:
 (2) Medicaid
 (2) BC/BS Plans
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Enhanced Ambulatory Patient Groups (EAPGs)
Defined
 EAPGs are a patient classification system designed to explain the amount and type
of resources used in an ambulatory visit. Patients in each EAPG have similar
clinical characteristics and similar resource use and cost.
 EAPGs were developed to encompass the full range of Ambulatory settings
including same day surgery units, hospital emergency rooms, and outpatient clinics.
 EAPGs can not address nursing home services, inpatient services or miscellaneous
services like transportation.
 EAPGs developed to represent ambulatory care across all payers, not just
Medicare.
8
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Case Mix Complexity in EAPGs
 Surgeries, other procedures, tests
― Different EAPGs based on expected resource use (similar operating
time, medical surgical supplies, etc)
― Example: (4) EAPGs for differing levels of laceration repair differentiated by extent
and complexity of repair
 Medical
― Different EAPGs based on expected resource use (similar visit time,
medical supplies, etc)
― Example: extreme acute manifestation of disease (ketoacidosis in a
diabetic) are categorized into a separate medical EAPG
9
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Case Mix Complexity in EAPGs (Cont.)
Patients may be assigned, and paid for, more than one EAPG
per visit
 One for medical visit including routine ancillary services (e.g.
chest x-ray, urine test) assigned and paid
 Additional EAPG(s) may be assigned and paid for non-routine
services (blood clotting factor test)
 Multiple distinct procedures have separate EAPGs assigned
and paid
10
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EAPG Based Payment System
 Each EAPG has an associated relative weight for payment
 Weights indicate the relative resource utilization among all
ambulatory services
― Resource intensive services have higher weights
 EAPG payment for a visit is computed as the sum of the
payment weights for all non consolidated, non packaged
EAPGs with applicable multiple procedure discounts applied.
 Incentive for efficient use of routine ancillary services is created
by significant procedure consolidation and by the packaging of
routine ancillaries into base visit payment
•
11
No incremental payment for routine, low cost ancillaries (blood chemistry, chest xray, ekg, etc.)
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EAPGs vs. DRGs
 DRGs
― Describes an inpatient
admission
― Uses discharge date to define
code sets
― Based on Dx and Px codes
― Each admission assigned
only 1 DRG
 EAPGs
― Defines ambulatory visit
― Uses from date to define code
sets
― Based on Dx and Px codes
― Multiple EAPGs may be
assigned per visit – meaning
more than a single line item
receives payment
Note:
• Non-routine and high resource services are paid separately.
• More complex outpatient visits have more non-routine services and have more
payable EAPGs assigned.
12
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Outpatient prospective payment system (OPPS): A brief history
1990 - 3M Health Information
Systems delivers an OPPS under
contract with HCFA (now CMS) —
APGs are introduced
2007 - Non-Medicare cost controls renew
interest in APG-based OPPS. 3M
undertakes a major clinical update and
introduces 3M™ Enhanced APG System.
1994 - Iowa Medicaid implements
the first APG-based OPPS, and
other payers follow. APG v2.0
released.
2008 - New York Medicaid implements the
first 3M EAPG-based OPPS.
2000 - CMS implements APCs (an
APG derivative) as the Medicare
OPPS. APCs are Medicare-focused
and not fully prospective. Payers
move to APC-based OPPS.
13
2012 - Massachusetts Medicaid
implements 3M EAPG-based OPPS.
3M EAPGs are ICD-10 ready.
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Today - Other major payers continue to
adopt 3M EAPGs. 3M Health Information
Systems consistently delivers quarterly
regulatory updates to the 3M EAPG
methodology and grouping software and also
continues to refine the 3M EAPG products to
reflect current outpatient clinical practice.
3M Health Information Systems
APGs vs. EAPGs
 Updated for clinical relevancy
 More flexibility for implementing options within grouper
 Number of classifications
― APGs: 273
― EAPGs: 553 (version 3.8)




Increased number of medical and significant procedure groupings
Modifier usage
APG Types
EAPGs include significant increase in drugs groups
― Provides more granularity
― Addresses issues of high cost drugs
 EAPGs include DME
14
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EAPG types (Version 3.5, January 2011)
EAPG Type
 1
 2

21

22

23

24

25
 3
 4
 5
 6
 7
 8
15
Description
Per Diem
Significant Procedure
Physical Therapy & Rehab
Mental Health & Counseling
Dental Procedure
Radiologic Procedure
Other Diagnostic Procedure
Medical Visit
Ancillary
Incidental
Drug
DME
Unassigned
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All treated as significant
procedures for consolidation
and discounting purposes
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Types: APGs vs. EAPGs (version 3.4)
APGs
APG Type Description
5
Per Diem
1
Significant Px
7
Medical Visit
2
Anciallary Px
3
Incidental
4
Medical Visit Indicator
9
Error/unassigned
Total
16
Count
8
131
62
62
1
1
8
273
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EAPGs
EAPG Type Description
1
Per Diem
2
Significant Procedure
21
Physical Therapy & Rehab
22
Mental Health & Counseling
23
Dental Procedure
24
Radiologic Procedure
25
Other Diagnostic Procedure
Subtotal Sign Px
3
Medical Visit
4
Ancillary
5
Incidental
6
Drug
7
DME
8
Unassigned
TOTAL
Count
4
148
10
15
23
27
15
238
190
67
3
23
25
3
553
3M Health Information Systems
EAPGs vs. APCs: Grouping
17
Category
Number of groupings
APCs
802 APC groups
EAPGS
553 EAPG groups
Multiple service lines
Each reviewed
individually
• Paid by APC
• Paid by fee schedule
• Packaged
• Rejected/denied –
OCE edits
Each reviewed individually
and assigned to EAPGs, as
appropriate, all lines assigned a
EAPG
Editing
• Claim denials
• Claim rejections
• Claim suspensions
• Claim RTP
• Line item denial
• Line item rejection
Extensive edits –
83 OCE edits
Almost no editing within
grouper
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EAPGs vs. APCs: Grouping; p2
Category
Status indicators
Types
Categories
18
APCs
EAPGS
Many
Not used
Examples:
• A – service paid by fee schedule
• S – paid by APC: sign. px
• T – paid by APC: sign. Px with discounting
• N – packaged service; no separate payment
• V – paid by APC: medical visit
None
13 EAPG types
Examples:
 Significant Procedure
 Medical Visit
 Ancillary
None
54
Examples:
• Musculoskeletal system procedures
• Pulmonary system procedures
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EAPGs vs. APCs: Grouping; p3
Category
Condition codes
Value codes
Inpatient only list
Packaging
19
APCs
Moderate use
• G0
• 20
• 21
Used:
• Ambulance
• Blood deductible
Used – defined by CMS
Packaging by line item –
status indicator N
consolidation
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EAPGS
Very limited use
Not used
Used – defined by select
agency
Extensive
• Significant procedure
• Ancillary packaging
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EAPGs vs. APCs: Reimbursement
Category
APCs
Discounting
• Discontinued
procedures
• Multiple T-type procedures
• 50%
20
Pass-through devise
Paid @ cost (charge
payments
times CCR)
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EAPGS
• Multiple EAPGs
• Discontinued procedures
• Multiple levels available(e.g.. 100%;
50%; 25%) allowed
Concept not used
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Summary EAPG vs. APC
APC (Medicare)
Methodology
Efficiency
Comprehensiveness
Medical Payment
Basis
Setting and Scope
EAPG
Primarily a payment classification system
and fee schedule of individual outpatient
procedures/services
Minimal packaging of ancillaries and
bundling of procedures
Excludes many services, which are then
covered under other fee schedules
Medical APCs pay based on self-reported
effort (duration of patient contact)
Applicability limited to payment for facility
cost for hospital based outpatient services
and ambulatory surgery centers
Payment structure based on services
utilization
Subject to federal decisions on editing and
Local control
payment policy
Large volume of fee schedule payments limit
Integral measurement development of broad comparative values
such as CMI
methodology
Unit of Service
21
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Outpatient visit classification system, which
places patients and services into clinically
coherent groups that can be used for service
line management
Comprehensive packaging and bundling
Covers all medical outpatient services
Medical APGs pay based on patient’s
condition (diagnosis and procedure). Greater
clinical focus
Broader applicability to other services and
settings (e.g., Mental Hygiene, Physical
Therapy, and Occupational Therapy) and to
performance reporting
Payment structure based on patient visit
Provides for local control of payment
policies
Claim weights provide foundation for
evaluation of outpatient care using CMI type
methodology, due to inclusion of all services
in classification system
Used with permission: G. Allen, NY DoH and adapted by DNFee
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3M™ Enhanced Ambulatory Patient Groups
Logical Functions within Products
Reimbursement
Calculated*
Grouping function
performed
What will be paid?
Editing if defined
*Policy decisions made by implementing payer
22
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EAPG Logic
YES
Type of
procedure
or therapy
Significant procedures
or therapies present
NO
Major signs,
symptoms
or findings
present
YES
Medical visit
indicator
EAPG present
Primary dx
code
NO
NO
Ancillary
tests or
procedures
present
23
Significant procedure
or therapy visit EAPG
Major
SSF
EAPG
NO
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Assign ancillary
(additional) EAPGs
Medical visit EAPG
Types of
ancillary tests
or procedures
YES
Assignment of
additional SP or
therapy EAPGs
Ancillary only visit
EAPG
Error
EAPG
3M Health Information Systems
Sample EAPG Assignments
HCPCS
20808
20816
20822
20824
20827
20838
20900
20902
20910
20912
20920
20922
20924
20926
20930
20931
Description
EAPG EAPG Type EAPG Category
Replantation hand complete
993
8
99
Replantation digit complete
993
8
99
Replantation digit complete
34
2
3
Replantation thumb complete
993
8
99
Replantation thumb complete
34
2
3
Replantation foot complete
993
8
99
Removal of bone for graft
31
2
3
Removal of bone for graft
32
2
3
Remove cartilage for graft
13
2
1
Remove cartilage for graft
13
2
1
Removal of fascia for graft
14
2
1
Removal of fascia for graft
14
2
1
Removal of tendon for graft
31
2
3
Removal of tissue for graft
14
2
1
Sp bone algrft morsel add-on
490
5
30
Sp bone algrft struct add-on
221
2
11
543 EAPGs defined
24
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EAPG Types
EAPG Type
 1
 2

21

22

23

24

25
 3
 4
 5
 6
 7
 8
25
Description
Per Diem
Significant Procedure
Physical Therapy & Rehab
Mental Health & Counseling
Dental Procedure
Radiologic Procedure
Other Diagnostic Procedure
Medical Visit
Ancillary
Incidental
Drug
DME
Unassigned
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EAPG Categories (examples)
EAPG Category
 1
 2
 3
 4
 5
 6
 7
 8
 9
 10
 11
 16
 30
 71
 99
EAPG Category Description
Skin and integumentary system procedures
Breast procedures
Musculoskeletal system procedures
Pulmonary system procedures
Cardiothoracic procedures
Hematopoietic system procedures
Gastrointestinal system procedures
Genitourinary system procedures
Male Reproductive system procedures
Female Reproductive system procedures
Neurologic system procedures
Mental illness and substance abuse therapies
Incidental procedures and services
Mental diseases and disorders
No EAPG assigned
 Total of 54 categories
26
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Three Types of Procedures in the EAPG System
SIGNIFICANT PROCEDURES: Normally scheduled, constitutes the
reason for the visit and dominates the time and resources expended
during the visit
Example: excision of skin lesion, stress tests
ANCILLARY TESTS AND PROCEDURES: Ordered by the primary
physician to assist in patient diagnosis or treatment
Example: immunizations, plain films, laboratory tests
INCIDENTAL PROCEDURE: An integral part of a medical visit and is
usually associated with professional services
Example: range of motion measurements
27
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Medical EAPGs
Describe patients who receive medical treatment but
do not have a significant procedure performed during
the visit.
Medical patients are described using the diagnoses
of the patient coded in ICD-9-CM.
28
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Medical visit EAPG – Assigned with Primary Dx Code
 Assigned based on primary dx code
― UB-04 form locator 67 (field attributes: 1 field; 1 line)
― X12, 837
•
Loop ID – 2300; Reference Indicator – H101-C022-02; X12 Element # – 1271;
Data Element Qualifier – 1270-BK or ABF for ICD10
― Definition: “The ICD-9-CM code for the diagnosis, condition, problem, or
other reason for encounter/visit shown in the medical record to be chiefly
responsible for the services provided. List additional codes that describe any
coexisting conditions. In some cases the first-listed diagnosis may be a
symptom when a diagnosis has not been established (confirmed) by the
physician..” (ICD-9-CM Official Guidelines for Coding and Reporting, October 1, 2008, Section IV.H, Page 102)
 Requires a medical visit indicator code
― E&M CPT code
 The medical visit EAPG is assigned to the E&M code
29
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Medical visit - Angina
30
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Medical Visit - Heartburn
31
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Packaging
 Sometimes referred to as bundling
 General concept:
For payment purposes, the inclusion of payment for certain
services within payment for significant procedures or medical
services.
 A concept/phrase to learn and know
― Just because something does not have separate payment, does not
mean it receives no payment
― A bundled/packaged service receives no separate payment
32
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Packaging – The General Concept
 EAPG standard logic includes
― Consolidation (significant procedure consolidation)
― Ancillary packaging
33
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EAPG Packaging – Standard Grouping Logic
 Significant procedure consolidation
― Same EAPG
― Clinical (related procedures)
 Ancillary packaging
― Uniform list of ancillary EAPGS
― Always packaged when other EAPG is present
34
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Uniform Packaging List
EAPG EAPG Description
EAPG
EAPG Description
373
LEVEL I DENTAL FILM
413
CARDIOGRAM
374
LEVEL II DENTAL FILM
423
INTRODUCTION OF NEEDLE AND CATHETER
375
DENTAL ANESTHESIA
424
DRESSINGS AND OTHER MINOR PROCEDURES
376
DIAGNOSTIC DENTAL PROCEDURES
425
377
PREVENTIVE DENTAL PROCEDURES
OTHER MISCELLANEOUS ANCILLARY
PROCEDURES
380
ANESTHESIA
426
PSYCHOTROPIC MEDICATION MANAGEMENT
390
LEVEL I PATHOLOGY
427
BIOFEEDBACK AND OTHER TRAINING
394
LEVEL I IMMUNOLOGY TESTS
428
PATIENT EDUCATION INDIVIDUAL
396
LEVEL I MICROBIOLOGY TESTS
429
PATIENT EDUCATION GROUP
398
LEVEL I ENDOCRINOLOGY TESTS
448
EXPANDED HOURS ACCESS
400
LEVEL I CHEMISTRY TESTS
449
402
BASIC CHEMISTRY TESTS
ADDITIONAL UNDIFFERENTIATED MEDICAL
VISIT/SERVICES
406
LEVEL I CLOTTING TESTS
457
VENIPUNCTURE
408
LEVEL I HEMATOLOGY TESTS
471
PLAIN FILM
410
URINALYSIS
411
BLOOD AND URINE DIPSTICK TESTS
412
35
SIMPLE PULMONARY FUNCTION
TESTS
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Ancillary Packaging
 Ancillary service is packaged when:
― The EAPG into which the service is groups is on the packaging list
― A medical visit EAPG is present, OR
― A significant procedure is present
 If ancillary service is provided alone
― No packaging is done
36
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Example of Ancillary Packaging
CPT
EAPG
Code Assigned EAPG Description
45385
137
Therapeutic colonoscopy
88304
390
Level I pathology
82947
402
Basic chemistry tests
84233
399
Level II endocrinology tests
93000
413
Cardiogram
37
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Action
Include in payment
Package
Package
Include in payment
Package
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Ancillary Packaging
P. dx: 38300 Ac mastoiditis w/o complication
38
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Ancillary service w/o Medical Visit or
Significant Px EAPG
PDX: 38300 Ac mastoiditis w/o complication
39
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Packaging
 Includes a packaging algorithm.
 Users will have the option to turn off/on packaging.
 Users will be able to make modifications to the
packaging lists.
 Users will be allowed to change (add to / delete from
the packaging list).
40
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EAPG Packaging Controls
41
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EAPG packaging – Standard Grouping Logic
 Significant procedure consolidation (bundling)
― Same EAPG
― Clinical (related procedures)
 Ancillary packaging
― Uniform list of ancillary EAPGS
― Always packaged when other EAPG is present
42
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Significant Procedure Consolidation
 When a patient has multiple significant procedures,
some of the significant procedures may require minimal
additional time or resources. Significant procedure
consolidation refers to the collapsing of multiple related
significant procedure APGs into a single EAPG for the
purpose determining the payment.
 Example: If both a simple incision and an complex
incision are coded on a patient bill, only the complex skin
incision will be used in the EAPG payment computation.
43
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Consolidation Controls
 Types of consolidation
― Multiple same procedure
― Clinical (based on clinical algorithm)
44
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Clinical Significant Procedure Consolidation Example
45
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Example of Clinical Significant Procedure
Consolidation
PDX: 9562 Inj posterior tib nerve
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Example of same SP consolidation
Diagnosis:
9100 Abrasion head
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Consolidation Controls
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Never Pay Services
 Carve outs
 Services that are just not covered by the payer
― Examples: cosmetic surgery
 Services are just paid through another mechanism – billed differently
― Possible example: vaccines that are paid through federal grants and
not included in the PPS
 Grouper allows never pay services to be defined by HCPCS code or
EAPG
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Never Pay Services
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CPT Modifiers that may have EAPG impact
 Modifiers recognized in EAPGs
― 25 – Distinct service
• Allows reimbursement for a medical visit (E&M) EAPG on the same day as a distinct and
separate significant procedure
― 27 – Multiple E&M encounters
• Allows reimbursement for multiple non-related medical visits (multiple E&M codes) on the
same date of service.
― 50 – Bilateral procedure
• Flags PX code for additional payment
― 52 – Discontinue service
• Payment discounted
― 59 – Distinct procedure
• Bypasses consolidation for line item with modifier
• Line item paid
― 73 – Terminated procedure
• Payment discounted
― GN, GO, GP for speech, occupational, and physical therapies (not used)
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Inpatient Only List
 Same concept as under APCs
 List slightly different than Medicare’s list
― Less restrictive
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List of Codes - Observation
 EAPGS
―
―
―
―
―
―
EAPG
450
492
500
501
502
EAPG Description
OBSERVATION
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION - OBSTETRICAL
ENCOUNTER/REFERRAL FOR OBSERVATION - OTHER DIAGNOSES
ENCOUNTER/REFERRAL FOR OBSERVATION - BEHAVIORAL HEALTH
EAPG Type
4 (Ancillary)
5 (Incidental)
3 (Medical)
3 (Medical)
3 (Medical)
EAPG Category
23
30
50
50
50
 Observation visit indicators (OVI)
―
―
―
―
―
―
―
―
―
―
―
―
HCPCS
99217
99218
99219
99220
99224
99225
99226
99234
99235
99236
G0379
HCPCS Description
Observation care discharge
Initial observation care
Initial observation care
Initial observation care
Subsequent observation care
Subsequent observation care
Subsequent observation care
Observation/hosp same date
Observation/hosp same date
Observation/hosp same date
Direct refer hospital observation
EAPG
492
492
492
492
492
492
492
492
492
492
492
EAPG Description
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR
 Observation
―
G0378
Hospital observation per hr
450
OBSERVATION
 Other
―
53
Medical Visit Indicators (MVI) [Series of E&M codes for clinic and ED visits]
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Observation Logic
 All observation is packaged in presence of significant
procedure or per diem EAPGs
 HCPCS G0378 is present
 Two types of observation
― Ancillary EAPG
― Medical EAPG
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Observation Logic
Ancillary Observation EAPG
 MVI also present
― MVI assigned to medical visit and paid
 Ancillary observation services:
― G0378 reported with hours of observation (usually a minimum of 8 hours)
• Assigned to EAPG 450 (“Observation” , weight = 2.194900), paid separately based on packaging
logic
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Observation Logic
Medical observation assignment
 Medical observation EAPG assignment
― Must be present:
• OVI - code assigned to EAPG 492 (“ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR”)
• Ancillary observation EAPG 450 (“Observation”)
― Exception
• If no EAPG 450, OVI is assigned EAPG 999
• If no OVI, but MVI is present, normal medical visit logic applied for the MVI
― Final medical observation EAPG assignment is driven by primary dx code
― EAPG 492 changes to one of three medical EAPGs (if all criteria met)
• 500 ENCOUNTER/REFERRAL FOR OBSERVATION - OBSTETRICAL
• 501 ENCOUNTER/REFERRAL FOR OBSERVATION - OTHER DIAGNOSES
• 502 ENCOUNTER/REFERRAL FOR OBSERVATION - BEHAVIORAL HEALTH
― EAPG 450 is packaged
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Observation Logic
HCPCS G0378 Present on claim?
MVI
only
Sign Px or
PerDiem
EAPG
present?
Yes
G0378 assigned to
EAPG 450 and is
packaged
57
No
OVI and/or
MVI
present?
Yes
MVI assigned medical
EAPG based on
primary dx code ;
HCPCS G0378
assigned to EAPG 450
and paid separately,
based on packaging
logic
OR
OVI
only
No
OVI assigned to
medical observation
EAPG (500 – 502)
based on primary dx
code; G0378 assigned
to EAPG 450 and is
packaged
OR
G0378 assigned to
EAPG 999
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MVI
and
OVI
OVI assigned to
medical observation
EAPG; G0378
assigned to EAPG
450 and packaged;
MVI assigned to 491
and packaged
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Logical Functions within Products
How much will it be paid?
Grouping performed
function
Editing if defined
*Policy decisions made by implementing payer
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Reimbursement
Calculated*
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Payment Formula
 Items consolidated, packaged, not grouped paid $0.00
 Conversion factor (CF) [also called the base rate] x
― TIMES
 EAPG weights
Adjusted weight (AW)
― TIMES
 Discount percentage
 Line items summed for visit total
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How are they paid?
Services reported:
•
Revenue code only
•
HCPCS codes included
Grouped services
Significant Px
Consolidation
Ancillary
Packaging
Lines
paid
CF * AW = line item payment
CF * AW = line item payment
CF * AW = line item payment
CF * AW = line item payment
Sum of line items payments = Total Payment
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Multiple Significant Procedure Discounting
 When multiple significant procedures or therapies are
performed, a discounting of the EAPG payment is
applied.
Discounting refers to a reduction in the
standard payment rate for an EAPG. Discounting
recognizes that the marginal cost of providing a
second procedure to a patient during a single visit is
less than the cost of providing the procedure by itself.
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Discounting Example
 Multiple unconsolidated significant procedure EAPGs
― Level 1 – 100% (highest weighted EAPG)
― Level 2 – 50%
― Level 3 and greater – 25%
 Multiple unpackaged ancillaries
― Repeat same ancillary EAPGs
•
Level 1 – 100%
•
Level 2 – 50%
•
Level 3 and greater – 25%
― Multiple different ancillary EAPGs
 Modifiers
― 50 – Bilateral procedure
•
62
Flags PX code for additional payment – 150%
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Discounting Example
63
HCPCS
code
35476
36120
72193
Desciption
Repair venous blockage
Establish access to artery
Ct pelvis w/dye
80053
85610
75790
75978
Comprehen metabolic panel
Prothrombin time
Visualize A-V shunt
Repair venous blockage
Final EAPG Adjusted
Pay
EAPG
Type
weight
percent
Pay action
Payment
85 Sign Px 14.0636 100.00% Full payment $3,886.90
280 Sign Px
5.3728 50.00% Discounted $1,484.93
301 Sign Px
0.3246 25.00% Discounted
$89.72
403
406
474
474
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Ancill
Ancill
Ancill
Ancill
0.3618 100.00% Full payment
$99.99
0.00
0.00%
Packaged
$0.00
2.9696 100.00% Full payment
$820.74
1.4848 50.00% Discounted
$410.37
Total
$6,792.65
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340b Drug Programs
 Pre-defined and pre-set
 Based on end-user reporting
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User-Defined 340B Drug EAPG
EAPG version 3.8
 EAPG 1090 – “USER DEFINED 340B DRUGS”
― Purpose:
• Provide users a method to customize a list of HCPCS codes representing drugs subject to the 340B
Drug Rebate Program
― No codes automatically assigned
― User to assign codes for this EAPG, restricted to those assigned to EAPG with
EAPG type 6, “Drugs”
― Provides ability to provide a discount for the payment of these drugs
― Functionality:
• If drug HCPCS code added to list, assigned to EAPG 1090 instead of standard EAPG
― Why?
• Allows for assignment of a weight to this EAPG, even standard EAPG is packaged, and
• For packaging of low cost drugs, and still pay for drugs on 340b list, in compliance with
CMS requirements
― Packaging and discounting logic not applied
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New Flags: Modifier UD other Option for 340b drugs
EAPG version 3.4 – 3.8
 Modifier UD – state defined modifier
 Provider reports modifier with drug code
 Payer may then use this as an indicator for payment
differentiation for drugs that may be part of a 340b drug
program
 Grouper outputs a flag to indicate the modifier was reported
 Alternative to handling 340b drugs
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Single Visit (Episode) vs. Multiple Visit Processing
 Multiple visit claims (claims with different from and through
dates)
― Most claims treated as multiple claims
― Determined by the line item dates of service
― A single claim may include services provided on two or more days
•
Ex: surgical work up and then a same day surgery a few days later
•
Series services, such as therapies, or wound care
― For payment purposes services provided on a single day (based on
line item dates of service) are treated a logic visits
― Packaging and discounting performed based on the visit and not the
claim
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Single Visit (Episode) vs. Multiple Visit Processing
(Cont.)
 Single visit claims (episodes)
― All services reported on a claim are treated as a single visit for
payment purposes
•
Claims when the from and through date are equal, and
•
When specific revenue codes are present regardless if the from and through
dates are equal
– For example: revenue codes: 450, 451, 452, 456, 459, 762
― Packaging and discounting performed for the entire claim
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Data Requirements
 Standard data sets [UB-04, X12-837I (institutional)]
― What codes are needed for each line item?
•
Revenue codes
― Codes usually required, but not always
•
HCPCS/CPT PX codes
•
HCPCS/CPT modifiers, as appropriate
― Charges
•
Comment on labs (CMS uses special lab panel logic for automated tests)
― ICD-9-CM DX codes needed on each claim
69
•
Primary DX, always
•
Reason for visit DX, for unscheduled visits, as coded
•
As many secondary DXs, as coded
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Data Requirements (cont.)
 Other data fields
― Age
― Gender
― Disposition
― Some condition and value codes
― Units of service
― Charges (particularly for clinical labs)
•
Comment on labs (CMS uses special lab panel logic for automated
tests)
― Line item dates of service
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3M Software
 3M will create a WA State specific grouper and
reimbursement formula
 3M supplies each state grouper to other grouper
vendors
 3M EAPG software:
― Integrated with coding system/HIM
― Batch version usually used in billing office
― Included in other 3M ambulatory management products
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