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3M™ Enhanced Ambulatory Patient Groups (EAPGs)

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Learn more about 3M™ Enhanced Ambulatory Patient Groups (EAPGs)
Bundle related services into logical groups for classification, payment and reporting
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3M EAPGs are specifically designed for today’s complex ambulatory environment.

Reflecting the care that today’s outpatient facilities provide

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.

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3M EAPGs: Offering the right incentives to the hospital

When Wellmark® Blue Cross® and Blue Shield® implemented the 3M™ Enhanced Ambulatory Patient Groups (EAPGs), the payer hoped to incentivize and reward hospitals for efficiently delivering good patient outcomes.

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Mike Fay - Measuring cost and quality
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Why choose the 3M EAPGs?

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.

  • All patient populations

    Appropriate for all patient populations

    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.

  • Clincally meaningful

    Clinically meaningful

    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.

  • Appropriate bundling

    Appropriate bundling

    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.

  • Flexible use cases

    Flexible use cases

    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.


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All about 3M EAPGs

The 3M EAPG methodology is critical to appropriate outpatient classification

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.

  • Definition
    3M EAPGs are designed to explain the amount and type of resources used in an ambulatory visit. These resources include pharmaceuticals, supplies, ancillary tests, equipment, type of room, treatment time, etc. Patients in each 3M EAPG share similar clinical characteristics, resource use and costs.
  • 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:
     

    • For payers, setting appropriate incentives. Implementing a 3M EAPG payment method rewards efficiency, not only because of bundling but also because payment does not depend on provider-specific costs or charges. Such an approach creates incentives for greater access to care, since payment is higher for more costly patients.
    • For hospitals and other providers, predicting and verifying expected payment. 3M makes available payment prediction software so providers can predict and verify expected payment using a specific payer’s 3M EAPG pricing policy. To see what payer-specific grouping and payment prediction software is available by state, click here.
    • Public reporting. Because 3M EAPGs define an outpatient visit, they are useful in public reporting and other comparisons across hospitals and states. For example, Florida uses 3M EAPGs for comparing volume and charges across hospitals and ASCs.
    • Quality comparisons. 3M EAPGs are used in defining Potentially Preventable Visits and Potentially Preventable Services, which are important measures of effectiveness in managing population health.
    • Clinical insight. Hospitals, other providers, government agencies, payers and researchers can use 3M EAPGs to yield insights about clinical care, case mix and common reasons for emergency department visits.
    • Financial analysis. Hospitals, other providers, government agencies, payers and researchers can apply 3M EAPGs to financial measures such as charges, costs and payments to create fair comparisons of utilization and efficiency across providers, attending physicians or service lines.
    • Defining episodes. The occurrence of an outpatient visit can define an episode of care that includes the outpatient visit, the associated hospital and professional services and related post-acute services such as rehabilitation.
  • 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).

    To see what payer-specific grouping and payment prediction software is available by state, click here.

    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.
     

    • 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™ Potentially Preventable Visit (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™ Potentially Preventable Service (PPS) methodology compares services with their indicated diagnoses to identify potentially preventable ancillary services. For example, 3M EAPG 294 MRI – Back is considered a potentially preventable service when the diagnosis is spinal stenosis.
    • 3M EAPGs are used to define certain 3M™ Patient Focused Episodes. 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:
     

    • 3M™ 360 Encompass™ System
    • 3M™ Performance Matrix Platform
    • 3M™ Coding and Reimbursement System Plus
    • 3M™ Clinical Documentation Improvement (CDI) System
    • 3M™ Reimbursement Calculation Software
    • 3M™ Core Grouping Software (CGS)
    • 3M™ Grouper Plus Content Services (GPCS)
    • 3M EAPG mainframe version

    Licensees of the 3M EAPG methodology have access to the following documents on the 3M customer support website:
     

    • 3M EAPG Methodology Overview
    • 3M EAPG Definitions Manual
    • 3M EAPG Preview of Changes
    • 3M EAPG Change Report
    • 3M EAPG Software Library
    • 3M EAPG Code Listings (Microsoft® Excel file)
    • 3M EAPG National Weights (Microsoft® Excel file)
  • 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.

  • Development:

    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 healthcare 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:
     

    • Ancillary packaging: Refers to the inclusion of related ancillary services into the 3M EAPG payment rate for a significant procedure or medical visit. An example would be packaging of routine blood tests.
    • Significant and other procedure consolidation: Refers to the collapsing of multiple clinically related procedure 3M EAPGs into a single 3M EAPG to determine payment.  For example, when a claim includes both 3M EAPG 3 Level I Skin Incision and Drainage and 3M EAPG 6 Level I Skin Debridement and Destruction, then 3M EAPG 3 is consolidated into 3M EAPG 7. 3M EAPG 3 is shown on the claim but with zero payment.
    • Discounting: Refers to a reduction in the 3M EAPG relative weight (and therefore the payment) when the same procedure is performed more than once during the same visit. An example would be bilateral myringotomies.

    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.

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