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3M EAPGs are specifically designed for today’s complex ambulatory environment.
The 3M™ Enhanced Ambulatory Patient Grouping (EAPG) System is a methodology that captures the current changes in clinical practice and resource use to provide a broader, more inclusive classification of outpatient care.
Using the 3M EAPG methodology, providers can more easily manage the complexity of outpatient claims, identify cost recovery opportunities, and improve both outpatient coding compliance and reimbursement.
3M EAPGs bring clinical insight and appropriate incentives to the historically jumbled world of outpatient utilization and payment.
As of March 2021, 12 state Medicaid programs and six major commercial payers use 3M EAPGs to reimburse providers. More than 1,000 provider organizations have licensed 3M EAPGs to predict and verify payment as well as analyze and improve internal operations.
EAPGs are suitable for all patient populations treated in emergency departments, other hospital outpatient departments, ambulatory surgical centers (ASCs) and other diagnostic and treatment clinics. Medicare Ambulatory Payment Classifications (APCs), by contrast, are designed and implemented for the specific needs of the Medicare population.
3M EAPGs are designed to explain the amount and type of resources used in an ambulatory visit or define the product of ambulatory care. That creates a common language for clinicians and financial managers to understand utilization patterns and evaluate comparative efficiency. EAPGs are also used in measuring quality outcomes, such as potentially preventable ED visits.
The unit of analysis should be the visit, not individual services. EAPGs define the visit, including appropriate bundling policies such as packaging, consolidation and discounting, to reflect provider resources typically expended for ambulatory visits.
EAPGs offer multiple options to fit the analytical and policy needs of payers and providers. Examples include packaging ancillary services, discounting multiple procedures within the same visit, paying or not paying for multiple medical visits in the same day.
All about 3M EAPGs
3M EAPGs encompass emergency departments, other hospital outpatient departments, ambulatory surgical centers and other diagnostic and treatment clinics. In addition, 3M EAPGs can be used for phone contacts, home visits and physician visits.
3M EAPGs are used by payers, hospitals, ASCs, other providers, government agencies and researchers. Payers often turn to 3M EAPGs as the basis for an outpatient prospective payment system. Providers combine 3M EAPGs with 3M payer-specific reimbursement calculation software to forecast and verify expected reimbursement. Payers, providers, government agencies and researchers rely on 3M EAPGs to understand outpatient utilization, measure quality and calculate measures of efficiency, such as cost per visit.
Here are a few examples of how the 3M EAPG patient classification methodology can bring value:
3M EAPG grouping logic is the same for every payer, although different payers can choose different configuration options and may follow different update schedules. Each payer that uses 3M EAPGs makes its own decisions about prices and payment policies. For hospitals, other providers, health plans and other organizations that seek to understand, predict and verify expected payment, 3M makes available software that emulates payer-specific grouping, pricing and reimbursement policies. This reimbursement calculation software is available for 18 payers nationwide (as of 2021).
See what payer-specific grouping and reimbursement calculation software is available by state.
3M also makes available outpatient reimbursement calculation software for national payers that do not use 3M EAPGs, such as the CMS APCs.
The 3M EAPGs are integrated with other 3M patient classification methodologies.
3M has aligned the service line definitions between 3M EAPGs for outpatient care and the 3M™ All Patient Refined Diagnosis Related Groups (APR DRGs) for inpatient care. This alignment allows analysis of charges, costs, payments and utilization by service line across both inpatient and outpatient settings.
The 3M PPV methodology uses 3M EAPGs to define potentially preventable emergency department visits. A common example is 3M EAPG 562 Infections of Upper Respiratory Tract and Otitis Media.
The 3M PPS methodology compares services with its indicated diagnoses to identify potentially preventable ancillary services. For example, 3M EAPG 450 observation is considered a potentially preventable service when the diagnosis is other family psycho/social circumstances.
3M EAPGs are used to define certain 3M™ Patient-focused Episodes (PFE) Software. For example, 3M EAPG 086 (Pacemaker and Other Cardiovascular Device Insertion and Replacement) triggers Patient Focused Episode 0860 (Pacemaker Insertion and Replacement).
The 3M EAPGs are available in the following 3M products:
Licensees of the 3M EAPG methodology has access to the following documents on the 3M customer support website:
3M experts are available to advise provider organizations, health plans, government agencies and other interested parties on how to obtain maximum value from the use of 3M EAPGs. For example, 3M consultants can help hospitals and clinics implement clinical documentation integrity programs and use the 3M EAPGs to measure and improve cost efficiency and quality of care. 3M consultants can also help payers design payment methods based on the 3M EAPGs and apply the 3M EAPGs to understand patterns of utilization, charges, cost and payment.
The unit of analysis is an outpatient visit. All the data required to assign 3M EAPGs can be obtained from standard claim forms, such as the UB-04 form for hospital outpatient care, the CMS 1500 form for services provided by ASCs and clinics, and the X12N 837 electronic counterparts of those forms. Data fields that are particularly important for 3M EAPG assignment include all diagnosis codes, procedure codes defined by the Current Procedural Terminology (CPT®) and the Healthcare Common Procedure Coding System (HCPCS), modifiers, service units and service dates.
In 1990, following the success of the Medicare Inpatient Prospective Payment System (IPPS) based on DRGs, the U.S. Congress required the Centers for Medicare & Medicaid Services (CMS) to develop an outpatient prospective payment system (OPPS). The contract to develop APGs was awarded to 3M. Throughout the 1990s, six major payers implemented payment methods based on APGs.
In 1999, however, congressional action required the new Medicare method to take more of a fee schedule approach. Payment based on APCs was implemented in August 2000. Because APCs took a fee schedule approach and had a high degree of Medicare specificity, there was demand from other payers and health care organizations for a different approach. In response, 3M developed the 3M EAPGs which were first released in 2007 and have since become the industry standard alternative to APCs.
3M EAPGs are designed to categorize, in a clinically meaningful way, the resources used to provide different types of care in various outpatient settings. If there is a significant procedure present, such as a laparoscopic cholecystectomy, the visit is a significant procedure visit and related ancillary services are bundled into the significant procedure. If there is no significant procedure, then the algorithm checks for a medical visit indicator. If present, the visit is a medical visit (e.g., for abdominal pain), and related ancillary services are bundled into the medical visit EAPG. If there is neither a significant procedure nor a medical visit indicator, then the visit is an ancillary visit. Services such as lab and imaging are paid individually, with discounting of related services.
These three 3M EAPG policies provide important incentives for efficiency and cost control:
The clinical logic is maintained by a team of 3M clinicians, data analysts, programmers and economists. The 3M proprietary logic is available for licensees to view in an online definition’s manual.
Each year, 3M calculates and releases a set of statistics for each 3M EAPG based on our analysis of large national data sets. These statistics include a relative weight for each 3M EAPG. The relative weight reflects the average resource use for a patient in that 3M EAPG relative to a subset of common ambulatory services, please note that payers and other users of the 3M EAPG methodology are responsible for using relative weights appropriate for their populations.
3M EAPGs can be rolled up into broader categories. The 648 3M EAPGs in version 3.16 (2021) roll up into 13 3M EAPG types, such as 2—Significant Procedure and 3—Medical Visit. The 3M EAPGs also roll up into 61 categories, such as 15—Radiologic Procedures and 62—Diabetes Mellitus.
In addition, each 3M EAPG is assigned to a service line aligned with the inpatient service lines defined by the 3M APR DRGs. An example is service line 8 Interventional Cardiology. This categorization allows analysis of charges, cost, payment and utilization by service line to comprise both inpatient and outpatient care.
3M releases a new version of the 3M EAPGs every January. It is updated each quarter with new codes that become effective in April, July or October. New versions reflect enhancements to the 3M EAPG clinical logic as well as quarterly updates for new HCPCS and CPT codes and for the annual update to ICD-10-CM diagnosis codes.
Learn more about 3M EAPGs
Please note that documents not published by 3M do not necessarily reflect 3M recommendations and have not been approved by 3M. These documents are listed here for the information of readers interested in the various ways that 3M patient classification methodologies have been applied. Also note that listing these references does not imply endorsement of 3M methodologies by individual authors, other organizations or government agencies.
Some articles and reports are available from the publishers at no charge, while others require a fee.
In this journal article, 3M researchers reviewed the components of an outpatient prospective payment system and described improvements to the APG methodology that resulted in 3M Enhanced Ambulatory Patient Groups.
In this report for the Medicare Payment Advisory Commission, a researcher described the evolution of Medicare prospective payment for outpatient services.
This report is an example of an outpatient hospital prospective payment method that uses 3M EAPG for case mix adjustment. The payment method was implemented by Florida Medicaid on July 1, 2013.
In this 2021 study, 3M researchers used 3M EAPGs to estimate that 55 percent of emergency department visits by a cohort of 1.4 million Medicare beneficiaries were for potentially preventable reasons such as minor musculoskeletal and skin problems.
Researchers used 3M APR DRGs and 3M EAPGs to calculate risk-adjusted differences in payment levels to individual hospitals by Medicare, Medicaid and commercial insurers.
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