© 3M 2012. All Rights Reserved. 3M provides these slides to promote a better understanding of 3M's software and/or services. These slides contain 3M confidential

© 3M 2012. All Rights Reserved. 3M provides these slides to promote a better understanding of 3M's software and/or services. These slides contain 3M confidential information and are for customer’s internal review only.

3M Health Information Systems

3M™ Ambulatory Patient Grouping System (EAPGs)

Innovating

HealthLanguage

ofthe

Washington State Hospital Association Feb 26, 2013

2 © 3M 2012. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.


Agenda Introductions 3M role Rationale for EAPG EAPGs compared to DRG, APC, APG EAPG Grouping Features EAPG Reimbursement Features Service mix index Questions and discussion



3M’s Role 3M HIS specializes in classification systems (groupers) using

coded claims data for health data analysis and payment Provider market focus: the clinical record

― Creating (dictation/transcription) and managing it (document management and abstracting)

― Coding, coding compliance, managing coding process

― Grouping and reimbursement for managing expected reimbursement

Payer market focus: help payers bend the cost curve by deploying groupers for payment and for quality-based payment incentives



3M’s Role with Payment Initiatives

We:• Create payment weights

• Create payment policy “levers” (outlier thresholds, policy adjustors (e.g. DSH)

• Provide instructions and support

• Share information about what other states have done

• Create state-specific grouper and payment formula

We do not:• Require the use of 3M weights

• “Pull the levers”



More on 3M’s Role with Payment Initiatives (Cont.)

Grouper Logic is transparent Availability of EAPG Definitions Manual to all at N/C Provider Education involving WSHA, WHA, 3M



Rationale for Use of EAPG for Payment Payers can best understand and manage outpatient costs by

implementing an outpatient prospective payment system (OPPS). There are only two OPPS available: APCs and EAPGs

EAPGs are superior to APCs especially for Medicaid programs:

• Designed for a all-patient rather than for just a Medicare population

• Cover all outpatient services rather than aligning with Medicare payment policy that uses fee schedules for certain services (e.g., therapies, clinical labs, chemotherapy drugs )

• Classify medical outpatient visits based on diagnoses-not E&M codes matching payment to need and permitting service site neutrality of payment

• Bundling features create incentives for efficiency



EAPGs In Use TodayOK BC/BS (2009)NY Medicaid (2010)VA Medicaid - ASCs (2010)IA BC/BS (2010)SD BC/BS (2010)Announced:VA Medicaid – Hospitals (2013)IL Medicaid (2013)WI Medicaid (2013)MN BC/BS (2013)In Consideration for 2013:(2) Medicaid(2) BC/BS Plans



Enhanced Ambulatory Patient Groups (EAPGs) Defined 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.

EAPGs can not address nursing home services, inpatient services or miscellaneous

services like transportation.

EAPGs developed to represent ambulatory care across all payers, not just

Medicare.



Case Mix Complexity in EAPGs

Surgeries, other procedures, tests― Different EAPGs based on expected resource use (similar operating

time, medical surgical supplies, etc)― Example: (4) EAPGs for differing levels of laceration repair differentiated by extent

and complexity of repair

Medical ― Different EAPGs based on expected resource use (similar visit time,

medical supplies, etc)

― Example: extreme acute manifestation of disease (ketoacidosis in a diabetic) are categorized into a separate medical EAPG



Case Mix Complexity in EAPGs (Cont.)

Patients may be assigned, and paid for, more than one EAPG per visit

One for medical visit including routine ancillary services (e.g. chest x-ray, urine test) assigned and paid

Additional EAPG(s) may be assigned and paid for non-routine services (blood clotting factor test)

Multiple distinct procedures have separate EAPGs assigned and paid



EAPG Based Payment System Each EAPG has an associated relative weight for payment Weights indicate the relative resource utilization among all

ambulatory services― Resource intensive services have higher weights

EAPG payment for a visit is computed as the sum of the payment weights for all non consolidated, non packaged EAPGs with applicable multiple procedure discounts applied.

Incentive for efficient use of routine ancillary services is created by significant procedure consolidation and by the packaging of routine ancillaries into base visit payment

• No incremental payment for routine, low cost ancillaries (blood chemistry, chest x-ray, ekg, etc.)



EAPGs vs. DRGs

DRGs― Describes an inpatient

admission

― Uses discharge date to define code sets

― Based on Dx and Px codes

― Each admission assigned only 1 DRG

EAPGs― Defines ambulatory visit

― Uses from date to define code sets

― Based on Dx and Px codes

― Multiple EAPGs may be assigned per visit – meaning more than a single line item receives payment

Note: • Non-routine and high resource services are paid separately.• More complex outpatient visits have more non-routine services and have more payable

EAPGs assigned.



Outpatient prospective payment system (OPPS): A brief history

1990 - 3M Health Information Systems delivers an OPPS under contract with HCFA (now CMS) —APGs are introduced

1994 - Iowa Medicaid implements the first APG-based OPPS, and other payers follow. APG v2.0 released.

2000 - CMS implements APCs (an APG derivative) as the Medicare OPPS. APCs are Medicare-focused and not fully prospective. Payers move to APC-based OPPS.

2007 - Non-Medicare cost controls renew interest in APG-based OPPS. 3M undertakes a major clinical update and introduces 3M™ Enhanced APG System.

Today - Other major payers continue to adopt 3M EAPGs. 3M Health Information Systems consistently delivers quarterly regulatory updates to the 3M EAPG methodology and grouping software and also continues to refine the 3M EAPG products to reflect current outpatient clinical practice.

2012 - Massachusetts Medicaid implements 3M EAPG-based OPPS.

3M EAPGs are ICD-10 ready.

2008 - New York Medicaid implements the first 3M EAPG-based OPPS.



APGs vs. EAPGs Updated for clinical relevancy More flexibility for implementing options within grouper Number of classifications

― APGs: 273― EAPGs: 553 (version 3.8)

Increased number of medical and significant procedure groupings Modifier usage APG Types EAPGs include significant increase in drugs groups

― Provides more granularity― Addresses issues of high cost drugs

EAPGs include DME



EAPG types (Version 3.5, January 2011)

EAPG Type Description 1 Per Diem 2 Significant Procedure 21 Physical Therapy & Rehab 22 Mental Health & Counseling 23 Dental Procedure 24 Radiologic Procedure 25 Other Diagnostic Procedure 3 Medical Visit 4 Ancillary 5 Incidental 6 Drug 7 DME 8 Unassigned

All treated as significant procedures for consolidation and discounting purposes



Types: APGs vs. EAPGs (version 3.4)

APG Type Description Count5 Per Diem 81 Significant Px 1317 Medical Visit 622 Anciallary Px 623 Incidental 14 Medical Visit Indicator 19 Error/unassigned 8

Total 273

APGsEAPG Type Description Count

1 Per Diem 42 Significant Procedure 14821 Physical Therapy & Rehab 1022 Mental Health & Counseling 1523 Dental Procedure 2324 Radiologic Procedure 2725 Other Diagnostic Procedure 15

Subtotal Sign Px 2383 Medical Visit 1904 Ancillary 675 Incidental 36 Drug 237 DME 258 Unassigned 3

TOTAL 553

EAPGs



EAPGs vs. APCs: GroupingCategory APCs EAPGSNumber of groupings 802 APC groups 553 EAPG groups

Multiple service lines Each reviewed Each reviewed individuallyindividually and assigned to EAPGs, as • Paid by APC appropriate, all lines assigned a • Paid by fee

schedule EAPG• Packaged • Rejected/denied – OCE edits

Editing Extensive edits – Almost no editing within • Claim denials 83 OCE edits grouper• Claim rejections• Claim suspensions• Claim RTP• Line item denial• Line item rejection



EAPGs vs. APCs: Grouping; p2Category APCs EAPGSStatus indicators Many Not used

Examples:• A – service paid by fee schedule• S – paid by APC: sign. px• T – paid by APC: sign. Px with discounting• N – packaged service; no separate payment• V – paid by APC: medical visit

Types None 13 EAPG typesExamples:

Significant Procedure Medical Visit Ancillary

Categories None 54Examples:• Musculoskeletal system procedures• Pulmonary system procedures



EAPGs vs. APCs: Grouping; p3

Category APCs EAPGSCondition codes Moderate use Very limited use

• G0• 20• 21

Value codesUsed: Not used• Ambulance• Blood deductible

Inpatient only list Used – defined by CMS Used – defined by select agency

Packaging Packaging by line item – Extensivestatus indicator N • Significant procedure consolidation• Ancillary packaging



EAPGs vs. APCs: Reimbursement

Category APCs EAPGS

Discounting • Discontinued • Multiple EAPGs

procedures • Discontinued procedures

• Multiple T-type procedures • Multiple levels available(e.g.. 100%;

• 50% 50%; 25%) allowed

Pass-through devise Paid @ cost (charge Concept not used

payments times CCR)



Summary EAPG vs. APCAPC (Medicare) EAPG

Methodology

Primarily a payment classification system and fee schedule of individual outpatient procedures/services

Outpatient visit classification system, which places patients and services into clinically coherent groups that can be used for service line management

EfficiencyMinimal packaging of ancillaries and bundling of procedures

Comprehensive packaging and bundling

ComprehensivenessExcludes many services, which are then covered under other fee schedules

Covers all medical outpatient services

Medical Payment Basis

Medical APCs pay based on self-reported effort (duration of patient contact)

Medical APGs pay based on patient’s condition (diagnosis and procedure). Greater clinical focus

Setting and Scope

Applicability limited to payment for facility cost for hospital based outpatient services and ambulatory surgery centers

Broader applicability to other services and settings (e.g., Mental Hygiene, Physical Therapy, and Occupational Therapy) and to performance reporting

Unit of ServicePayment structure based on services utilization

Payment structure based on patient visit

Local controlSubject to federal decisions on editing and payment policy

Provides for local control of payment policies

Integral measurement methodology

Large volume of fee schedule payments limit development of broad comparative values such as CMI

Claim weights provide foundation for evaluation of outpatient care using CMI type methodology, due to inclusion of all services in classification system

Used with permission: G. Allen, NY DoH and adapted by DNFee



3M™ Enhanced Ambulatory Patient GroupsLogical Functions within Products

Editing if defined

Grouping functionperformed

ReimbursementCalculated*

*Policy decisions made by implementing payer

What will be paid?



EAPG Logic

Significant procedures or therapies present

Type of procedure or therapy

Significant procedure or therapy visit EAPG

YES

NO

Medical visit indicator EAPG present

Major signs, symptoms or findings present

YES

Ancillary tests or procedures present

NO

Major SSF EAPG

Primary dx code

NOMedical visit EAPG

Types of ancillary tests or procedures

YES

Ancillary only visit EAPG

Error EAPG

NO

Assignment of additional SP or therapy EAPGs

Assign ancillary (additional) EAPGs



Sample EAPG AssignmentsHCPCS Description EAPG EAPG Type EAPG Category

20808 Replantation hand complete 993 8 9920816 Replantation digit complete 993 8 9920822 Replantation digit complete 34 2 320824 Replantation thumb complete 993 8 9920827 Replantation thumb complete 34 2 320838 Replantation foot complete 993 8 9920900 Removal of bone for graft 31 2 320902 Removal of bone for graft 32 2 320910 Remove cartilage for graft 13 2 120912 Remove cartilage for graft 13 2 120920 Removal of fascia for graft 14 2 120922 Removal of fascia for graft 14 2 120924 Removal of tendon for graft 31 2 320926 Removal of tissue for graft 14 2 120930 Sp bone algrft morsel add-on 490 5 3020931 Sp bone algrft struct add-on 221 2 11

543 EAPGs defined



EAPG Types

EAPG Type Description 1 Per Diem 2 Significant Procedure 21 Physical Therapy & Rehab 22 Mental Health & Counseling 23 Dental Procedure 24 Radiologic Procedure 25 Other Diagnostic Procedure 3 Medical Visit 4 Ancillary 5 Incidental 6 Drug 7 DME 8 Unassigned



EAPG Categories (examples)

EAPG Category EAPG Category Description 1 Skin and integumentary system procedures 2 Breast procedures 3 Musculoskeletal system procedures 4 Pulmonary system procedures 5 Cardiothoracic procedures 6 Hematopoietic system procedures 7 Gastrointestinal system procedures 8 Genitourinary system procedures 9 Male Reproductive system procedures 10 Female Reproductive system procedures 11 Neurologic system procedures 16 Mental illness and substance abuse therapies 30 Incidental procedures and services 71 Mental diseases and disorders 99 No EAPG assigned

Total of 54 categories



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 testsANCILLARY TESTS AND PROCEDURES: Ordered by the primary

physician to assist in patient diagnosis or treatmentExample: immunizations, plain films, laboratory tests

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

Example: range of motion measurements



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.



Medical visit EAPG – Assigned with Primary Dx Code 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



Medical visit - Angina



Medical Visit - Heartburn



Packaging

Sometimes referred to as bundling General concept:

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

A concept/phrase to learn and know― Just because something does not have separate payment, does not

mean it receives no payment

― A bundled/packaged service receives no separate payment



Packaging – The General Concept

EAPG standard logic includes― Consolidation (significant procedure consolidation)

― Ancillary packaging



EAPG Packaging – Standard Grouping Logic

Significant procedure consolidation ― Same EAPG

― Clinical (related procedures)

Ancillary packaging― Uniform list of ancillary EAPGS

― Always packaged when other EAPG is present



Uniform Packaging List EAPG EAPG Description373 LEVEL I DENTAL FILM

374 LEVEL II DENTAL FILM

375 DENTAL ANESTHESIA

376 DIAGNOSTIC DENTAL PROCEDURES

377 PREVENTIVE DENTAL PROCEDURES

380 ANESTHESIA

390 LEVEL I PATHOLOGY

394 LEVEL I IMMUNOLOGY TESTS

396 LEVEL I MICROBIOLOGY TESTS

398 LEVEL I ENDOCRINOLOGY TESTS

400 LEVEL I CHEMISTRY TESTS

402 BASIC CHEMISTRY TESTS

406 LEVEL I CLOTTING TESTS

408 LEVEL I HEMATOLOGY TESTS

410 URINALYSIS

411 BLOOD AND URINE DIPSTICK TESTS

412 SIMPLE PULMONARY FUNCTION TESTS

EAPG EAPG Description413 CARDIOGRAM

423 INTRODUCTION OF NEEDLE AND CATHETER

424 DRESSINGS AND OTHER MINOR PROCEDURES

425 OTHER MISCELLANEOUS ANCILLARY PROCEDURES

426 PSYCHOTROPIC MEDICATION MANAGEMENT

427 BIOFEEDBACK AND OTHER TRAINING

428 PATIENT EDUCATION INDIVIDUAL

429 PATIENT EDUCATION GROUP

448 EXPANDED HOURS ACCESS

449 ADDITIONAL UNDIFFERENTIATED MEDICAL VISIT/SERVICES

457 VENIPUNCTURE

471 PLAIN FILM



Ancillary Packaging

Ancillary service is packaged when:― The EAPG into which the service is groups is on the packaging list

― A medical visit EAPG is present, OR

― A significant procedure is present

If ancillary service is provided alone― No packaging is done



Example of Ancillary Packaging

CPT Code

EAPG Assigned EAPG Description Action

45385 137 Therapeutic colonoscopy Include in payment88304 390 Level I pathology Package82947 402 Basic chemistry tests Package84233 399 Level II endocrinology tests Include in payment93000 413 Cardiogram Package



Ancillary PackagingP. dx: 38300 Ac mastoiditis w/o complication



Ancillary service w/o Medical Visit or Significant Px EAPG

PDX: 38300 Ac mastoiditis w/o complication



Packaging

Includes a packaging algorithm. Users will have the option to turn off/on packaging. Users will be able to make modifications to the

packaging lists. Users will be allowed to change (add to / delete from

the packaging list).



EAPG Packaging Controls



EAPG packaging – Standard Grouping Logic

Significant procedure consolidation (bundling)― Same EAPG

― Clinical (related procedures)

Ancillary packaging― Uniform list of ancillary EAPGS

― Always packaged when other EAPG is present



Significant Procedure Consolidation

When a patient has multiple significant procedures, some of the significant procedures may require minimal additional time or resources. Significant procedure consolidation refers to the collapsing of multiple related significant procedure APGs into a single EAPG for the purpose determining the payment.

Example: If both a simple incision and an complex incision are coded on a patient bill, only the complex skin incision will be used in the EAPG payment computation.



Consolidation Controls

Types of consolidation― Multiple same procedure

― Clinical (based on clinical algorithm)



Clinical Significant Procedure Consolidation Example



Example of Clinical Significant Procedure Consolidation PDX: 9562 Inj posterior tib nerve



Example of same SP consolidation

Diagnosis:9100 Abrasion head



Consolidation Controls



Never Pay Services

Carve outs Services that are just not covered by the payer

― Examples: cosmetic surgery Services are just paid through another mechanism – billed differently

― Possible example: vaccines that are paid through federal grants and not included in the PPS

Grouper allows never pay services to be defined by HCPCS code or EAPG



Never Pay Services



CPT Modifiers that may have 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. ― 50 – Bilateral procedure

• Flags PX code for additional payment― 52 – Discontinue service

• Payment discounted― 59 – Distinct procedure

• Bypasses consolidation for line item with modifier• Line item paid

― 73 – Terminated procedure • Payment discounted

― GN, GO, GP for speech, occupational, and physical therapies (not used)



Inpatient Only List

Same concept as under APCs List slightly different than Medicare’s list

― Less restrictive



List of Codes - Observation EAPGS

― EAPG EAPG Description EAPG Type EAPG Category

― 450 OBSERVATION 4 (Ancillary) 23― 492 ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR 5 (Incidental) 30― 500 ENCOUNTER/REFERRAL FOR OBSERVATION - OBSTETRICAL 3 (Medical) 50― 501 ENCOUNTER/REFERRAL FOR OBSERVATION - OTHER DIAGNOSES 3 (Medical) 50― 502 ENCOUNTER/REFERRAL FOR OBSERVATION - BEHAVIORAL HEALTH 3 (Medical) 50

Observation visit indicators (OVI)― HCPCS HCPCS Description EAPG EAPG Description― 99217 Observation care discharge 492 ENCOUNTER/REFERRAL FOR OBSERVATION

INDICATOR― 99218 Initial observation care 492 ENCOUNTER/REFERRAL FOR OBSERVATION



INDICATOR― 99224 Subsequent observation care 492 ENCOUNTER/REFERRAL FOR OBSERVATION



INDICATOR― 99234 Observation/hosp same date 492 ENCOUNTER/REFERRAL FOR OBSERVATION



INDICATOR― G0379 Direct refer hospital observation 492 ENCOUNTER/REFERRAL FOR OBSERVATION

INDICATOR Observation

― G0378 Hospital observation per hr 450 OBSERVATION Other

― Medical Visit Indicators (MVI) [Series of E&M codes for clinic and ED visits]



Observation Logic

All observation is packaged in presence of significant procedure or per diem EAPGs

HCPCS G0378 is present

Two types of observation ― Ancillary EAPG― Medical EAPG



Observation Logic

MVI also present― MVI assigned to medical visit and paid

Ancillary observation services:― G0378 reported with hours of observation (usually a minimum of 8 hours)

• Assigned to EAPG 450 (“Observation” , weight = 2.194900), paid separately based on packaging logic

Ancillary Observation EAPG



Observation Logic

Medical observation EAPG assignment― Must be present:

• OVI - code assigned to EAPG 492 (“ENCOUNTER/REFERRAL FOR OBSERVATION INDICATOR”)• Ancillary observation EAPG 450 (“Observation”)

― Exception • If no EAPG 450, OVI is assigned EAPG 999• If no OVI, but MVI is present, normal medical visit logic applied for the MVI

― Final medical observation EAPG assignment is driven by primary dx code― EAPG 492 changes to one of three medical EAPGs (if all criteria met)

• 500 ENCOUNTER/REFERRAL FOR OBSERVATION - OBSTETRICAL• 501 ENCOUNTER/REFERRAL FOR OBSERVATION - OTHER DIAGNOSES• 502 ENCOUNTER/REFERRAL FOR OBSERVATION - BEHAVIORAL HEALTH

― EAPG 450 is packaged

Medical observation assignment



Observation Logic

OVI assigned to medical observation EAPG (500 – 502) based on primary dx code; G0378 assigned to EAPG 450 and is packaged

Sign Px or PerDiem EAPG

present?

OVI and/or MVI

present?

No

HCPCS G0378 Present on claim?

G0378 assigned to EAPG 450 and is packaged

YesNo

MVI only

OVI only

MVI and OVI

MVI assigned medical EAPG based on primary dx code ; HCPCS G0378 assigned to EAPG 450 and paid separately, based on packaging logic

OVI assigned to medical observation EAPG; G0378 assigned to EAPG 450 and packaged; MVI assigned to 491 and packaged

Yes

G0378 assigned to EAPG 999

OR

OR



Logical Functions within Products

Editing if defined

Grouping performedfunction

ReimbursementCalculated*

How much will it be paid?

*Policy decisions made by implementing payer



Payment Formula

Items consolidated, packaged, not grouped paid $0.00 Conversion factor (CF) [also called the base rate] x

― TIMES

EAPG weights― TIMES

Discount percentage

Line items summed for visit total

Adjusted weight (AW)



How are they paid?

Lines paid

Services reported:• Revenue code only• HCPCS codes included

Grouped services Significant PxConsolidation

AncillaryPackaging

CF * AW = line item payment




Sum of line items payments = Total Payment



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.



Discounting Example

Multiple unconsolidated significant procedure EAPGs

― Level 1 – 100% (highest weighted EAPG)

― Level 2 – 50%

― Level 3 and greater – 25%

Multiple unpackaged ancillaries

― Repeat same ancillary EAPGs

• Level 1 – 100%

• Level 2 – 50%

• Level 3 and greater – 25%

― Multiple different ancillary EAPGs

Modifiers― 50 – Bilateral procedure

• Flags PX code for additional payment – 150%



Discounting Example

HCPCS code Desciption

Final EAPG

EAPG Type

Adjusted weight

Pay percent Pay action Payment

35476 Repair venous blockage 85 Sign Px 14.0636 100.00% Full payment $3,886.9036120 Establish access to artery 280 Sign Px 5.3728 50.00% Discounted $1,484.9372193 Ct pelvis w/dye 301 Sign Px 0.3246 25.00% Discounted $89.72

80053 Comprehen metabolic panel 403 Ancill 0.3618 100.00% Full payment $99.9985610 Prothrombin time 406 Ancill 0.00 0.00% Packaged $0.0075790 Visualize A-V shunt 474 Ancill 2.9696 100.00% Full payment $820.7475978 Repair venous blockage 474 Ancill 1.4848 50.00% Discounted $410.37

Total $6,792.65



340b Drug Programs

Pre-defined and pre-set Based on end-user reporting



User-Defined 340B Drug EAPG

EAPG 1090 – “USER DEFINED 340B DRUGS” ― Purpose:

• Provide users a method to customize a list of HCPCS codes representing drugs subject to the 340B Drug Rebate Program

― No codes automatically assigned― User to assign codes for this EAPG, restricted to those assigned to EAPG with

EAPG type 6, “Drugs”― Provides ability to provide a discount for the payment of these drugs― Functionality:

• If drug HCPCS code added to list, assigned to EAPG 1090 instead of standard EAPG― Why?

• Allows for assignment of a weight to this EAPG, even standard EAPG is packaged, and• For packaging of low cost drugs, and still pay for drugs on 340b list, in compliance with

CMS requirements― Packaging and discounting logic not applied

EAPG version 3.8



New Flags: Modifier UD other Option for 340b drugs

Modifier UD – state defined modifier Provider reports modifier with drug code Payer may then use this as an indicator for payment

differentiation for drugs that may be part of a 340b drug program

Grouper outputs a flag to indicate the modifier was reported Alternative to handling 340b drugs

EAPG version 3.4 – 3.8



Single Visit (Episode) vs. Multiple Visit Processing Multiple visit claims (claims with different from and through

dates)― Most claims treated as multiple claims

― Determined by the line item dates of service

― A single claim may include services provided on two or more days• Ex: surgical work up and then a same day surgery a few days later

• Series services, such as therapies, or wound care

― For payment purposes services provided on a single day (based on line item dates of service) are treated a logic visits

― Packaging and discounting performed based on the visit and not the claim



Single Visit (Episode) vs. Multiple Visit Processing (Cont.)

Single visit claims (episodes)― All services reported on a claim are treated as a single visit for

payment purposes• Claims when the from and through date are equal, and

• When specific revenue codes are present regardless if the from and through dates are equal

– For example: revenue codes: 450, 451, 452, 456, 459, 762

― Packaging and discounting performed for the entire claim



Data Requirements Standard data sets [UB-04, X12-837I (institutional)]

― What codes are needed for each line item?

• Revenue codes

― Codes usually required, but not always

• HCPCS/CPT PX codes

• HCPCS/CPT modifiers, as appropriate

― Charges

• Comment on labs (CMS uses special lab panel logic for automated tests)

― ICD-9-CM DX codes needed on each claim

• Primary DX, always

• Reason for visit DX, for unscheduled visits, as coded

• As many secondary DXs, as coded



Data Requirements (cont.)

Other data fields― Age

― Gender

― Disposition

― Some condition and value codes

― Units of service

― Charges (particularly for clinical labs)

• Comment on labs (CMS uses special lab panel logic for automated tests)

― Line item dates of service



3M Software

3M will create a WA State specific grouper and reimbursement formula

3M supplies each state grouper to other grouper vendors

3M EAPG software: ― Integrated with coding system/HIM― Batch version usually used in billing office― Included in other 3M ambulatory management products

Documents

© 3M 2012. All Rights Reserved. 3M provides these slides to promote a better understanding of 3M's software and/or services. These slides contain 3M confidential