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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 their 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 November 2018, 12 state Medicaid programs and 17 other commercial payers also use 3M EAPGs to reimburse providers. Over 1,000 provider organizations have licensed 3M EAPGs to predict and verify payment as well as analyze and improve their internal operations.
In contrast to the Ambulatory Payment Classifications (APCs) used by the Centers for Medicare & Medicaid Services (CMS), 3M EAPGs are clinically defined to reflect services typically provided together during a patient visit to a hospital outpatient department, freestanding ambulatory surgical center (ASC), physician clinic, renal dialysis center and other diverse outpatient care settings.
Consider a patient who presents to the emergency department with chest pain, but does not undergo a significant procedure. For this visit, 3M EAPG 604–Chest Pain will be assigned. In contrast, the CMS APC code assigned to this same visit would be APC 5024--Level IV ED Visit.
The 3M EAPG methodology takes a more bundled approach than the CMS APCs, and an even more bundled approach than the fee schedule and percentage-of-charge methods still widely used for outpatient care. In the 3M EAPG methodology, routine ancillary services like x-rays and EKGs are often packaged, so there is no additional payment; procedures that are integral to other procedures are consolidated; and payment for add-on procedures is discounted. Efficiency incentives and analytical clarity are stronger under the 3M EAPGs than under APCs, and much stronger than the fee schedule and percentage-of-charge approaches.
Both payers and providers appreciate the flexibility of configuring the 3M EAPGs to meet their own needs. For example, 3M EAPG users may choose among several options for packaging ancillary services, discounting multiple occurrences of the same procedure, and paying or not paying for multiple medical visits in the same day.
All about 3M EAPGs
3M EAPGs encompass the full range of ambulatory settings, including same-day surgery units, hospital emergency rooms and outpatient clinics. In addition, 3M EAPGs can address phone contacts, home visits and physician visits.
3M EAPGs are used by payers, hospitals, ambulatory surgical centers (ASCs), physician clinics, other providers, government agencies and researchers. Payers often turn to 3M EAPGs as the basis for an outpatient prospective payment system for analyzing patterns of charges, costs and utilization. Providers combine 3M EAPGs with 3M payer-specific payment prediction software to forecast and verify expected reimbursement. 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 payment prediction software is available for 16 payers nationwide (as of 2018).
See what payer-specific grouping and payment prediction software is available by state.
3M also makes available outpatient payment prediction 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.
The 3M EAPGs are available in the following 3M products:
Licensees of the 3M EAPG methodology have 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 improvement programs and use the 3M EAPGs to measure and improve their own cost efficiency and quality of care. 3M consultants can also help payers to design payment methods based on the 3M EAPGs and to apply the 3M EAPGs to understanding 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 ambulatory surgical centers (ASCs) and physician 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 based on Diagnosis Related Groups, the U.S. Congress required the Centers for Medicare & Medicaid Services to develop an outpatient prospective payment system. The contract to develop Ambulatory Patient Groups (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 Ambulatory Payment Classifications (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 therefore developed the 3M™ Enhanced Ambulatory Patient Groups (EAPGs), which were first released in 2007 and have since become the 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 procedure is assigned to a significant procedure 3M EAPG and related ancillary services would be bundled with it. If there is no significant procedure, then the algorithm checks for a medical visit indicator. If present, a medical visit 3M EAPG is assigned, and related ancillary services are bundled with it. For example, consider an emergency department visit for chest pain. If there is neither a significant procedure nor a medical visit, then the services on the claim are assigned to ancillary 3M EAPGs.
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, nosologists, programmers and economists. The 3M-proprietary logic is available for licensees to view in an online definitions 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 the average 3M EAPG. 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 589 3M EAPGs in version 3.14 roll up into 13 3M EAPG types, such as 2—Significant Procedure and 3—Medical Visit. The 3M EAPGs also roll up into 55 categories, such as 15—Radiologic Procedures and 62—Diabetes Mellitus.
In addition, each 3M EAPG is assigned to a service line consistent with the inpatient service lines defined by the 3M™ All Patient Refined Diagnosis Related Groups (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. They 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.
The 3M EAPGs are designed to explain the amount and type of resources used in an ambulatory visit.
Learn how the 3M™ Enhanced Ambulatory Patient Grouping (EAPG) System can help transform patient data into actionable knowledge.
Wynn, Barbara. Medicare Payment for Hospital Outpatient Services: A Historical Review of Policy Options. Report for the Medicare Payment Advisory Commission. www.medpac.gov.
Prepared for the Florida Agency for Health Care Administration
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