3M Enhanced Ambulatory Patient Grouping System (EAPGS)

3M Health Information Systems, Inc. 3M™ Enhanced Ambulatory Patient Grouping System (EAPGS) Dave Fee, 3M Health Information Systems © 3M 2008. All r...
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3M Health Information Systems, Inc.

3M™ Enhanced Ambulatory Patient Grouping System (EAPGS) Dave Fee, 3M Health Information Systems

© 3M 2008. All rights reserved.

3M Health Information Systems, Inc.

Agenda  Review of EAPGS Definition of the Classification System    

Grouping Under EAPGs Procedure Groups Visits Standard & Enhanced Features • Consolidation • Packaging • Discounting • Modifiers • User Options

 3M EAPG products  Interfacing between 3M™ Core Grouping Software and other systems  Demo of 3M Core Grouping Software  

Prepared examples Examples from audience

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APG Time Line  Hospital Provider Training

June/July 2008

 General DTC Training

Oct. 29, 2008

 CMS Approval – Effective Date

Dec. 1, 2008

 Final APG Regulations

Dec. 3, 2008

 Implement APGs in Hospital OPDs and Amb Surg Units

Dec. 1, 2008

 Implement APGs in Hospital EDs

Jan. 1, 2009

 Implement APGs in D&TCs and in Amb Surg Centers

March 1, 2009

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Enhanced Ambulatory Patient Groups (EAPGs) A Definition 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. 4 © 3M 2007. 2008. All rights reserved.

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Example - classification HCPCPS  10081  10180  11975  11977  11981  19020  20005  21501  23030  23031  23930  23931  27301  27603  28002

HCPCS Description Drainage of pilonidal cyst Complex drainage, wound Insert contraceptive cap Removal/reinsert contra cap Insert drug implant device Incision of breast lesion Incision of deep abscess Drain neck/chest lesion Drain shoulder lesion Drain shoulder bursa Drainage of arm lesion Drainage of arm bursa Drain thigh/knee lesion Drain lower leg lesion Treatment of foot infection

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EAPG 004 LEVEL II SKIN INCISION AND DRAINAGE

Payment is based on the EAPG assigned

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Logical Functions within Products Reimbursement Calculated*

Grouping function performed

What will be paid?

Editing if defined

Codes entered into grouper 6 © 3M 2008. All rights reserved.

*Policy decisions made by NY DoH.

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Visit based  Based on the ambulatory visit 



EAPGS allow for segregation of multiple visits reported on a single claim based on line item dates of service ED visits claim equals the visit

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Wound care – multiple visits

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Wound care example HCPCS code Visit id 1: 97022 97001 99499 97606 97598 Visit Subtotal: Visit id 2: 97022 97001 99499 97606 Visit Subtotal: Visit id 3 : 97022 97001 99499 97606 97598 Visit Subtotal:

Code description

Final Adjusted EAPG weight

Payment Pay perc action

Base payment

Existing Blended Outlier payment payment payment

Whirlpool therapy Pt evaluation Unlisted e&m service Neg press wound tx, > 50 cm Active wound care > 20 cm

271 271 491 12 425

0.1749 50.00% Discounted 0 0.00% Consolidated 0 0.00% Packaged 2.0269 100.00% Full payment 0 0.00% Packaged

$38.42 $0.00 $0.00 $445.29 $0.00 $483.71

$3.67 $0.00 $0.00 $42.49 $0.00 $46.16

$9.61 $0.00 $0.00 $111.32 $0.00 $120.93

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Whirlpool therapy Pt evaluation Unlisted e&m service Neg press wound tx, > 50 cm

271 271 491 12

0.1749 50.00% 0 0.00% 0 0.00% 2.0269 100.00%

Discounted Consolidated Packaged Full payment

$38.42 $0.00 $0.00 $445.29 $483.71

$3.67 $0.00 $0.00 $42.49 $46.16

$9.61 $0.00 $0.00 $111.32 $120.93

$0.00 $0.00 $0.00 $0.00 $0.00

Whirlpool therapy Pt evaluation Unlisted e&m service Neg press wound tx, > 50 cm Active wound care > 20 cm

271 271 491 12 425

0.1749 50.00% Discounted 0 0.00% Consolidated 0 0.00% Packaged 2.0269 100.00% Full payment 0 0.00% Packaged

$38.42 $0.00 $0.00 $445.29 $0.00 $483.71

$3.67 $0.00 $0.00 $42.49 $0.00 $46.16

$9.61 $0.00 $0.00 $111.32 $0.00 $120.93

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$1,451.13

$138.48

$362.79

$0.00

Claim Total:

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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 10 © 3M 2008. All rights reserved.

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Three Types of Procedures in the EAPG System (Cont’d.)

INCIDENTAL PROCEDURE: An integral part of a medical visit and is usually associated with professional services

Example: range of motion measurements

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EAPG logic Type of procedure or therapy

YES Significant procedures or therapies present NO

Medical visit indicator APG present

Medical visit EAPG Primary dx code

NO NO

Types of ancillary tests or procedures

YES

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Major SSF EAPG

Major signs, symptoms or findings present

YES

Ancillary tests or procedures present

Significant procedure or therapy visit EAPG

NO

Ancillary only visit EAPG

Error EAPG

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CPT Modifiers with 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.  52 – Discontinue service • Payment discounted 50%  73 – Terminated procedure • Payment discounted 50%  59 – Distinct procedure • Bypasses consolidation for line item with modifier • Line item paid 100%  50 – Bilateral procedure • Flags PX code for additional payment – 150%

Note: Use of Modifiers 25 and 27 will not affect reimbursement inititally; important to code on claims nevertheless 13

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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.

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Medical visit EAPG  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

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Packaging  General concept: For payment purposes, the inclusion of payment for certain services within payment for significant procedures or medical services.

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Packaging – the general concept  EAPG logic includes 

Consolidation (significant procedure consolidation)



Ancillary packaging



Inpatient only list

 NY Dept of Health has implemented 

Additional EAPG to ancillary packaging list (EAPG 435)



Never-pay list



Stand alone, do not pay list

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EAPG packaging  Significant procedure consolidation (bundling) 

Same EAPG



Clinical (related procedures)

 Ancillary packaging 

Uniform list of ancillary EAPGS



Always packaged when other EAPG is present

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EAPGs excluded from same significant procedure consolidation – defined by NY DoH EAPG EAPG Description

EAPG EAPG Description

350

361 362 363 364 365 366 367

351 352 353 354 355 356 357 358 359 360

LEVEL I ADJUNCTIVE GENERAL DENTAL SERVICES LEVEL II ADJUNCTIVE GENERAL DENTAL SERVICES PERIODONTICS LEVEL I PROSTHODONTICS, FIXED LEVEL II PROSTHODONTICS, FIXED LEVEL III PROSTHODONTICS, FIXED LEVEL I PROSTHODONTICS, REMOVABLE LEVEL II PROSTHODONTICS, REMOVABLE LEVEL III PROSTHODONTICS, REMOVABLE LEVEL I MAXILLOFACIAL PROSTHETICS LEVEL II MAXILLOFACIAL PROSTHETICS

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368 369 370 371

LEVEL I DENTAL RESTORATIONS LEVEL II DENTAL RESTORATIONS LEVEL III DENTAL RESTORATION LEVEL I ENDODONTICS LEVEL II ENDODONTICS LEVEL III ENDODONTICS LEVEL I ORAL AND MAXILLOFACIAL SURGERY LEVEL II ORAL AND MAXILLOFACIAL SURGERY LEVEL III ORAL AND MAXILLOFACIAL SURGERY LEVEL IV ORAL AND MAXILLOFACIAL SURGERY ORTHODONTICS

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EAPG packaging  Ancillary packaging 

Uniform list of ancillary EAPGS



Always packaged when other EAPG is present

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Uniform Packaging List EAPG EAPG Description

EAPG EAPG Description

373 374 375 376 377 380 390 394 396 398 400 402 406 408 410 411 412

413 423

LEVEL I DENTAL FILM LEVEL II DENTAL FILM DENTAL ANESTHESIA DIAGNOSTIC DENTAL PROCEDURES PREVENTIVE DENTAL PROCEDURES ANESTHESIA LEVEL I PATHOLOGY LEVEL I IMMUNOLOGY TESTS LEVEL I MICROBIOLOGY TESTS LEVEL I ENDOCRINOLOGY TESTS LEVEL I CHEMISTRY TESTS BASIC CHEMISTRY TESTS LEVEL I CLOTTING TESTS LEVEL I HEMATOLOGY TESTS URINALYSIS BLOOD AND URINE DIPSTICK TESTS SIMPLE PULMONARY FUNCTION TESTS

424 425 426 427 428 429 435 448 449 457 471

CARDIOGRAM INTRODUCTION OF NEEDLE AND CATHETER DRESSINGS AND OTHER MINOR PROCEDURES OTHER MISCELLANEOUS ANCILLARY PROCEDURES PSYCHOTROPIC MEDICATION MANAGEMENT BIOFEEDBACK AND OTHER TRAINING PATIENT EDUCATION INDIVIDUAL PATIENT EDUCATION GROUP CLASS I PHARMACOTHERAPY EXPANDED HOURS ACCESS ADDITIONAL UNDIFFERENTIATED MEDICAL VISIT/SERVICES VENIPUNCTURE PLAIN FILM

Note: items in red added by NY DoH; items in green deleted by NY DoH 21 © 3M 2007. 2008. All rights reserved.

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Inpatient only list  List of services perceived to be unsafe to be performed in an outpatient setting 

No reimbursement provided for this list of services



1415 codes on the list

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Never Pay EAPGs  “Never Pay” EAPGs are those services that are not covered under EAPG reimbursement.  Examples of Never Pay EAPGs include: 

Respiratory Therapy



Cardiac Rehabilitation



Nutrition Therapy



Artificial Fertilization



Biofeedback

23

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“Never Pay” EAPGs (Zero Payment) APG 65 66 94 117 118 190 311 312 313 314 319 320 371 427 430 431 432 433 434 450 452 453 454 456 492 24

“NEVER PAY” APG RESPIRATORY THERAPY PULMONARY REHABILITATION CARDIAC REHABILITATION HOME INFUSION NUTRITION THERAPY ARTIFICIAL FERTILIZATION FULL DAY PARTIAL HOSP FOR SUBST ABUSE FULL DAY PARTIAL HOSP FOR MNTAL ILLNSS HALF DAY PARTIAL HOSP FOR SUBST ABUSE HALF DAY PARTIAL HOSP FOR MNTAL ILLNSS ACTIVITY THERAPY CASE MGMT – MNTAL HLTH OR SUBST ABUSE ORTHODONTICS BIOFEEDBACK & OTHR TRAINING CLASS I CHEMO DRUGS CLASS II CHEMO DRUGS CLASS III CHEMO DRUGS CLASS IV CHEMO DRUGS CLASS V CHEMO DRUGS OBSERVATION DIABETES SUPPLIES MOTOTIZED WHEELCHAIR TPN FORMULAE MOTORIZED WHEELCHAIR ACCESSORIES DIRECT ADMISSION FOR OBSRVATN INDICATR

500 DIRECT ADMISSION FOR OBSRVATN - OBSTET © 3M 2008. All rights reserved.

ALTERNATIVE FUNDING SOURCE

MNTL HYGIENE DENTAL FEE SCHED ORDERED ORDERED ORDERED ORDERED ORDERED

AMB AMB AMB AMB AMB

FEE FEE FEE FEE FEE

SCHED SCHED SCHED SCHED SCHED

PHARMACY DME FEE SCHED MEDICAL SUPPLIES DME FEE SCHED

24

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Additional services on Never Pay list

25

                           

HCPCS Code 20985 20986 20987 28890 70554 83655 87536 87901 87902 87903 87999 95012 95965 95966 1000F 4000F D9920 G0398 G0399 G0400 G8402 G8403 G9016 J0585 J0587 J0882 J0886

HCPCS Description Cptr-asst dir ms px Cptr-asst dir ms px io img Cptr-asst dir ms px pre img High energy eswt, plantar f Fmri brain by tech Assay of lead Hiv-1, dna, quant Genotype, dna, hiv reverse t Genotype, dna, hepatitis C Phenotype, dna hiv w/culture Microbiology procedure Exhaled nitric oxide meas Meg, spontaneous Meg, evoked, single Tobacco use assessed Tobacco use txmnt counseling Behavior management, by report Home sleep test/type 2 Porta Home sleep test/type 3 Porta Home sleep test/type 4 Porta Smoke preven interven counse Smoke preven nocounsel Demo-smoking cessation coun Botulinum toxin a per unit Botulinum toxin type B Darbepoetin alfa, esrd use Epoetin alfa 1000 units ESRD

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HCPCS Code J1440 J1441 J2505 J7187 J7189 J7190 J7191 J7192 J7193 J7194 J7195 J7197 J7198 J7199 J7300 J7302 J7307 S0190 S0191 S4989 S8940 S9075 S9128 S9129 S9131 S9453

HCPCS Description Filgrastim 300 mcg injection Filgrastim 480 mcg injection Injection, pegfilgrastim 6mg Humate-P, inj Factor viia Factor viii Factor VIII (porcine) Factor viii recombinant Factor IX non-recombinant Factor ix complex Factor IX recombinant Antithrombin iii injection Anti-inhibitor Hemophilia clot factor noc Intraut copper contraceptive Levonorgestrel iu contracept Etonogestrel implant system Mifepristone, oral, 200 mg Misoprostol, oral, 200 mcg Contracept IUD Hippotherapy per session Smoking cessation treatment Speech therapy, in the home, Occupational therapy, in the PT in the home per diem Smoking cessation class

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Never pay: example HCPCS code

Final EAPG

D0140 D0220 D0230 D2391 D2392 95012

491 373 373 361 361 999

Adjusted weight

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Pay percent

Base Existing Blended Outlier Add-on Pay action payment payment payment payment payment

0 0.00% Packaged 0.2624 100.00% Full payment 0.1312 50.00% Discounted 0.3385 100.00% Full payment 0.1693 50.00% Discounted 0 0.00% No payment

$0.00 $72.52 $36.27 $93.55 $46.79 $0.00

$0.00 $19.56 $9.78 $25.23 $12.62 $0.00

$0.00 $18.13 $9.06 $23.39 $11.70 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $12.10 $0.00 $0.00 TOTAL

Total line payment $0.00 $37.69 $18.84 $60.72 $24.32 $0.00 $141.57

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“If Stand Alone, Do Not Pay” EAPGs  “Stand Alone, Do Not Pay” EAPGs generally consist of procedures performed as follow-up to an initial clinic visit for which EAPGs will not pay. These consist primarily of tests and other ancillaries.  Mirroring the current reimbursement system, these procedures will also not pay under EAPGs when they are the only items claimed for a given date of service  Examples include: 



Follow-up laboratory and diagnostic radiology testing (except MRIs) related to an initial patient encounter. Immunizations.

 Providers should still claim for these procedures in order to maximize the available data that can be used for future reweighting and rebasing. 27

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“If Stand Alone, Do Not Pay” EAPGs 280 284 285 286 287 288 289 290 291 298 299 300 301 302 303 330 331 332 380 390 391 392 393 394 395 396 397 398 399

VASCULAR RADIOLOGY EXCEPT VENOGRAPHY OF EXTREMITY MYELOGRAPHY MISCELLANEOUS RADIOLOGICAL PROCEDURES WITH CONTRAST MAMMOGRAPHY DIGESTIVE RADIOLOGY DIAGNOSTIC ULTRASOUND EX OB AND VAS LOWER EXTR VASCULAR DIAGNOSTIC ULTRASOUND OF LOWER EXTREMITIES PET SCANS BONE DENSITOMETRY CAT SCAN BACK CAT SCAN - BRAIN CAT SCAN - ABDOMEN CAT SCAN - OTHER ANGIOGRAPHY, OTHER ANGIOGRAPHY, CEREBRAL LEVEL I DIAGNOSTIC NUCLEAR MEDICINE LEVEL II DIAGNOSTIC NUCLEAR MEDICINE LEVEL III DIAGNOSTIC NUCLEAR MEDICINE ANESTHESIA LEVEL I PATHOLOGY LEVEL II PATHOLOGY PAP SMEARS BLOOD AND TISSUE TYPING LEVEL I IMMUNOLOGY TESTS LEVEL II IMMUNOLOGY TESTS LEVEL I MICROBIOLOGY TESTS LEVEL II MICROBIOLOGY TESTS LEVEL I ENDOCRINOLOGY TESTS LEVEL II ENDOCRINOLOGY TESTS

28

400 401 402 403 404 405 406 407 408 409 410 411 413 414 415 416 435 436 437 438 439 451 455 457 470 471 472 473

LEVEL I CHEMISTRY TESTS LEVEL II CHEMISTRY TESTS BASIC CHEMISTRY TESTS ORGAN OR DISEASE ORIENTED PANELS TOXICOLOGY TESTS THERAPEUTIC DRUG MONITORING LEVEL I CLOTTING TESTS LEVEL II CLOTTING TESTS LEVEL I HEMATOLOGY TESTS LEVEL II HEMATOLOGY TESTS URINALYSIS BLOOD AND URINE DIPSTICK TESTS CARDIOGRAM LEVEL I IMMUNIZATION AND ALLERGY IMMUNOTHERAPY LEVEL II IMMUNIZATION LEVEL III IMMUNIZATION CLASS I PHARMACOTHERAPY CLASS II PHARMACOTHERAPY CLASS III PHARMACOTHERAPY CLASS IV PHARMACOTHERAPY CLASS V PHARMACOTHERAPY SMOKING CESSATION TREATMENT IMPLANTED TISSUE OF ANY TYPE VENIPUNCTURE OBSTETRICAL ULTRASOUND PLAIN FILM ULTRASOUND GUIDANCE CT GUIDANCE

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Example: standalone, do not pay

HCPCS code Visit id 1: 73700 Ct lower extremity w/o dye 80047 Metabolic panel ionized ca 36415 Routine venipuncture Visit Subtotal: Visit id 2: 29888 Knee arthroscopy/surgery 29889 Knee arthroscopy/surgery 29880 Knee arthroscopy/surgery 29879 Knee arthroscopy/surgery Visit Subtotal: Claim Total:

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Final Adjusted Payment EAPG weight Pay perc action 301 403 457

38 38 37 37

0 0 0

0.00% Standalone 0.00% Standalone 0.00% Standalone

17.9246 100.00% Full payment 0 0.00% Consolidated 0 0.00% Consolidated 0 0.00% Consolidated

Base payment

Existing Blended Outlier payment payment payment

$0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00

$3,937.86 $0.00 $0.00 $0.00 $3,937.86

$46.16 $0.00 $0.00 $0.00 $46.16

$984.47 $0.00 $0.00 $0.00 $984.47

$0.00 $0.00 $0.00 $0.00 $0.00

$3,937.86

$46.16

$984.47

$0.00

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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 for NY DoH  Multiple unconsolidated significant procedures  Multiple unpackaged ancillaries  Modifiers 

52 – Discontinue service • Payment discounted 50%



73 – Terminated procedure • Payment discounted 50%



59 – Distinct procedure • Bypasses consolidation for line item with modifier • Line item paid 100%



50 – Bilateral procedure • Flags PX code for additional payment – 150%

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Discounting example

HCPCS code Desciption Repair venous 35476 blockage Establish access to 36120 artery 72193 Ct pelvis w/dye Comprehen 80053 metabolic panel 85610 Prothrombin time 75790 Visualize A-V shunt Repair venous 75978 blockage TOTAL CLAIM

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Final EAPG

EAPG Type

Adjusted weight

85 Sign Px

14.0636

280 Sign Px 301 Sign Px

5.3728 0.6492

403 Ancill 406 Ancill

Pay percent

Pay action

100.00% Full payment

Base Existing Blendedpa Outlier Add-on yment payment payment payment payment $3,089.63

$26.07

$772.41

$0.00

$4.30

Discounted Discounted

$1,180.35 $142.62

$9.96 $1.20

$295.09 $35.66

$0.00 $0.00

$0.00 $0.00

0.3618 0.00

100.00% Full payment 0.00% Packaged

$79.49 $0.00

$0.68 $0.00

$19.86 $0.00

$0.00 $0.00

$0.00 $0.00

474 Ancill

2.9696

100.00% Full payment

$652.39

$5.50

$163.10

$0.00

$0.00

474 Ancill

1.4848

$2.75 $81.55 $46.16 $1,367.67

$0.00 $0.00

$0.00 $4.30

50.00% 50.00%

50.00%

Discounted

$326.20 $5,470.68

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Logical Functions within Products How much will it be paid?

Reimbursement Calculated*

Grouping performed function

Editing if defined

Codes entered into grouper 33 © 3M 2008. All rights reserved.

*Policy decisions made by payer.

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Payment logic

EAPG weight

Transition X Discounts X Base rate X multiplier

+

Percent of existing payment

+

During 4 year transition period For OPD services

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Capital add-on

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EAPG weight  Weight represents a comparison among EAPGs to define the relative difference in resources required to perform the service (based on cost)  Each EAPG is assigned a weight  This is not the payment rate

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Transition  Transition to 100% based on EAPG  

ED & ambulatory surgery – no transition 100% year 1 OPD – 4 year transition: • Year 1 = 25% EAPG/75% existing rate • Year 2 = 50%/50% • Year 3 = 75%/25% • Year 4 = 100%/0%

 Existing rate varies by hospital

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Provider Billing Changes  New APG Grouper Access Rate Codes  Effective 12/1/08  

Hosp Outpatient Clinic – 1400 Hosp Based Amb Surg – 1401

 Effective 1/1/09 

Hosp Emergency Dept – 1402

 Effective 3/1/09     

37

DTC General Clinic Rate Code - 1407 DTC Dental Rate Code - 1428 DTC Renal Rate Code - 1438 DTC MR/DD/TBI Patient - 1435 Free-Standing Ambulatory Surgery Rate Code - 1408

 New rate codes must be used for summiting claims based on the effective date of the facilities © 3M 2008. All rights reserved.

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Lab and Radiology Billing Under APGs  Lab and radiology services are included in the APG payment to clinic provider (excluding the aforementioned exceptions )  Clinic is responsible for payment for ordered lab and radiology services to provider of those services.  Therefore, other providers actually performing the lab/radiology service may not bill Medicaid.

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Thoughts on being successful with OPPS  Complete coding a requirement 

Hasn’t always been necessary

 Use new rate codes  Submit test claims  Being successful w/ EAPGS means being efficient in facility management  Consolidation/packaging of services very significant  Units of service does not impact payment  Can’t be efficient w/out management/reporting tools

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3M EAPG products  Interactive – 3M™ EAPGfinder  

Functions with 3M encoder Usually used in hospital HIM departments

 Batch 



3M™ Core Grouping Software (CGS) • Usually used in billing departments • Interfaces with billing/project management systems 3M™ Grouper Plus System (GPS) • Integrates with other systems • Can be used in multiple system functions • No native UPI

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3M EAPG products - functionality     

Grouping based on standard EAPG functionality Customized to support special NY requirements Calculates reimbursement, including NY definitions Interfacing Provide editing functions  



External to grouping and reimbursement Designed to make certain • Codes used are valid • Coding is complete Includes edits such as • Code validation • Sex and age related edits • NCCI facility edits • Etc. • 65 total edits

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Interfacing w/ CGS Claims submission to NY claims processor (CSC)

Provides Claims data: •all dx •all px codes •dates of service •age •gender

Functionality: •data storage •report writing •analysis features Flat file •comparison of payment vs expected payment •other standard Interface output file functions

Flat file

Interface input file

Note: HIPAA transactions highlighted in red © 3M 2008. All rights reserved.

835

837

Billing system

42

Remittance advice

3M CGS

Returns: Input data EAPGS EAPG detail expected reimbursement

Billing system

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Interface files  Standard ASCII  Fixed length fields  Fixed format structure

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Input interface format (excerpt)

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Output interface format (excerpt)

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References

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References  NY site for EAPG information: 

http://www.nyhealth.gov/health_care/medicaid/rates/apg/index.htm

 NY site for changes to 837 (claims submission) and 835 (remittance): 

http://www.emedny.org/HIPAA/emedny_transactions/transactions.html

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