by Jayme Bernier
Published 3 years ago
Updated 2 years ago
A3 – The EAPG methodology uses a facility base rate along with an EAPG-specific weight for each revenue line. It is necessary to purchase the 3M software to determine the weights assigned for each procedure based on the 3M software logic and DMAS reimbursement scheme settings. The processed claim will have the EAPG weight assigned to each line on the remittance advice. The sum of the EAPG weights times the facility-specific base rate determines the payment. There is no spreadsheet available for pricing claims.
Answer: The EAPG is just a code under which similar services are grouped. The weight associated with the EAPG can be found in a spreadsheet attached to the EAPG Page on the ForwardHealth Portal. To estimate your payment, multiply the weight associated with the EAPG times your provider rate.
The total allowable reimbursement per visit shall be determined by multiplying the hospital-specific base rate times the sum of the EAPG relative weights assigned to an outpatient hospital visit. Total estimated expenditures under the new methodology should be budget neutral or the same as total estimated expenditures under the old methodology.
What does eapg stand for?
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.
Where can I find the eapg weights and base rate?
The EAPG weights and the base rate are available on the DMAS website at www.dmas.virginia.gov. Click on Provider Services, Rate Setting Information, Outpatient Facility Rates, Outpatient Hospital EAPG. The weights will be updated at least every three years in concert with rebasing.
What is the unit of analysis for eapgs?
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.
Where to find EAPg consolidation logic?
The EAPG consolidation logic can be found on the NYS DOH website.
What is the EAPG code for outpatient clinics in New York?
Yes. The appropriate rate code for rural outpatient clinics (primary care only) is 1407. The table below gives the emergency department codes and the New York State Department of Health (NYS DOH) EAPG base rates.
What is an episode in APG billing?
An episode is "a unit of service consisting of all services on a claim, regardless of the coded dates of service." This type of billing applies to clinic and emergency department billing and is not applicable to ambulatory surgery billing.
What is an episode in APG?
An episode is "a unit of service consisting of all services on a claim, regardless of the coded dates of service.".
Is there a capital add on value for EAPG?
Normally, the capital add-on value is not zero, but there are a few exceptions where there is no capital add-on for certain services.
Is EAPg required on a bill?
The EAPG codes are not a required part of the bill. Providers/facilities can provide Current Procedural Terminology (CPT) codes. Bills should not be rejected if the EAPG codes are not listed.
Does the EAPG require insurance companies to reprice bills?
An insurance company must reprice and pay bills per the EAPG methodology. The Board does not reprice bills.
4 hours ago
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.
6 hours ago
· EAPG payment is based on the severity of an episode of care. The 2015 EAPG fee schedule has a NYS Workers' Compensation specific base rate that pays 150% of Medicaid hospital rates for upstate and downstate regions and includes the cost of implants in the relative weight of the procedure. Implants are not reimbursed as an add-on, and should be billed using …
25 hours ago
Classification through several visits. In most cases, the classification of EAPG happens with the number of visits made to the ambulatory care. A reimbursement of calculation of the care may represent the number of services that are provided on …
17 hours ago
· ForwardHealth uses the Enhanced Ambulatory Patient Group (EAPG) classification system to calculate pricing for outpatient hospital claims. The groups used in the EAPG system categorize the amount and type of resources used in various outpatient visits. Under the EAPG classification system, reimbursement for outpatient hospital services is based on the quantity …
33 hours ago
· Enhanced Ambulatory Patient Grouping Questions and Answers. The Enhanced Ambulatory Patient Groups (EAPG) system was implemented by ForwardHealth on April 1, 2013, to classify and calculate reimbursement for outpatient hospital services. Under the EAPG system, ForwardHealth reimburses hospital providers for outpatient services based on the quantity and …
15 hours ago
· The total allowable operating rate per visit is determined by multiplying the base rate times the sum of the EAPG relative weights assigned on the hospital claim. The statewide base rate shall be adjusted to be hospital-specific based on the geographic location of the hospital facility.
8 hours ago
The unit of analysis for the EAPG is the visit Multiple visits (dates of service) on one claim For example, several Physical Therapy visits all on one claim The EAPG grouper splits these so that 1 visit = 1 claim Exception: ED visits/Observation One visit visit can have several services
31 hours ago
Enhanced Ambulatory Patient Group (EAPG) Frequently Asked Questions Q: What are Enhanced Ambulatory Patient Groups (EAPGs)? A: EAPGs are a patient classiication system designed to explain the amount and type of resources used during an ambulatory visit. Patients in each EAPG have similar clinical characteristics, resource use and cost.
