Visante 
EAPG or the Enhanced Ambulatory Patient Grouping is among the models focused on transitioning fee for service to a value based payment. Over 25% of the state Medicaid programs in addition to several commercial payers have adopted the EAPG outpatient prospective payment system. 3M developed the methodology to provide greater uniformity in payments across multiple diverse outpatient areas and designed to represent all patients, not just Medicare.
There are 8 EAPG types that are assigned to each claim line to classify the services in a visit. The classification or logic is based on the presence of an APG (ambulatory procedure group), diagnosis codes, clinical signs and symptoms, and other ancillary tests. This form of classification is more complex and includes clinical variables within the visit than the traditional APC (ambulatory payment classification) system used by Medicare.
EAPG Types
Significant procedure, therapies, test
Ancillary services
Incidental procedures
Medical Visits
Drugs
Durable Medical Equipment
Per Diem
Unassigned
Once the EAPG is assigned it will pass through grouper functions that may apply pricing types including: full payment, consolidation, packaging, discounting or per diem to each individual line. Consolidation occurs when 2 or more significant procedures or clinically similar procedures are billed and only the primary or EAPG with highest weight receives full payment. Packaging occurs when ancillary services are used and considered to be part of the procedure, and discounting is payment receiving less than full payment.
Each state Medicaid program or insurer that utilizes the EAPG methodology will develop the organization’s base rate and may have some variances in how they determine what is consolidated, packaged or discounted. Base rates may be determined based on cost to charge ratio or have other formulas based on regional variation. Final payment then applies the following formula: base rate x EAPG weight x policy adjuster (e.g. modifiers) x discount factor = payment. Base rates and relative EAPG are typically published on Medicaid portals; however, crosswalks of HCPC to EAPG are not publicly available and should be sourced through 3M.
Shout Outs! Billing and revenue integrity teams should take some time and training to understand the implications of billing. Application and acceptance of modifiers and other billing requirements not addressed in this article may vary from traditional Medicare guidelines.
Revenue cycle and pharmacy teams should monitor payment from programs that utilize an EAPG methodology. High cost drugs entering the market may or may not be built within the EAPG methodology accurately resulting in revenue leakage.
