3M™ Enhanced Ambulatory Patient Groups (EAPGs)

3M EAPGs are used by payers, hospitals, ASCs, other providers, government agencies and researchers. Payers often turn to 3M EAPGs as the basis for an outpatient prospective payment system. 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.

Here are a few examples of how the 3M EAPG patient classification methodology can bring value:
 

• 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.
• Predict and verify expected payment. 3M makes available reimbursement calculation software so providers can predict and verify expected payment using a specific payer’s 3M EAPG pricing policy.
• Public reporting. Because 3M EAPGs define an outpatient visit, they are useful in public reporting and other comparisons across hospitals and states.
• Quality comparisons. 3M EAPGs are used in defining 3M™ Potentially Preventable Emergency Department Visits (PPVs) and 3M™ Potentially Preventable Services (PPSs), which are important measures of effectiveness in managing population health.
• Clinical insight. Hospitals, other providers, government agencies, payers and researchers 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 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 reimbursement calculation software is available for 18 payers nationwide (as of 2021).

3M also makes available outpatient reimbursement calculation 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 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 PPS methodology compares services with its indicated diagnoses to identify potentially preventable ancillary services. For example, 3M EAPG 450 observation is considered a potentially preventable service when the diagnosis is other family psycho/social circumstances.

3M EAPGs are used to define certain 3M™ Patient-focused Episodes (PFE) Software. 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™ Coding and Reimbursement System
• 3M™ Clinical Documentation Improvement (CDI) System
• 3M™ Reimbursement Calculation Software
• 3M™ Core Grouping Software (CGS)
• 3M™ Grouper Plus Content Services (GPCS)
• 3M™ Data to Action Solution
• 3M℠ Intelligent Data Asset
• 3M EAPG mainframe version

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

• 3M EAPG Methodology Overview
• 3M EAPG Definitions Manual
• 3M EAPG Summary of Changes
• 3M EAPG Installation and User's Guide for IBM® Mainframe Platforms
• 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 integrity programs and use the 3M EAPGs to measure and improve cost efficiency and quality of care. 3M consultants can also help payers design payment methods based on the 3M EAPGs and apply the 3M EAPGs to understand 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 ASCs and 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 (IPPS) based on DRGs, the U.S. Congress required the Centers for Medicare & Medicaid Services (CMS) to develop an outpatient prospective payment system (OPPS). The contract to develop 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 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 health care organizations for a different approach. In response, 3M developed the 3M EAPGs which were first released in 2007 and have since become the industry 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 visit is a significant procedure visit and related ancillary services are bundled into the significant procedure. If there is no significant procedure, then the algorithm checks for a medical visit indicator. If present, the visit is a medical visit (e.g., for abdominal pain), and related ancillary services are bundled into the medical visit EAPG. If there is neither a significant procedure nor a medical visit indicator, then the visit is an ancillary visit. Services such as lab and imaging are paid individually, with discounting of related services.

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, Debridement, Destruction, Other Related Px and 3M EAPG 16 Simple Wound Repair and Treatment, then 3M EAPG 16 is consolidated into 3M EAPG 3. 3M EAPG 16 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 two or more procedures are performed during the same visit. An example would be procedure on both the lower leg and the arm.

The clinical logic is maintained by a team of 3M clinicians, data analysts, programmers and economists. The 3M proprietary logic is available for licensees to view in an online definition’s 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 a subset of common ambulatory services, 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 648 3M EAPGs in version 3.16 (2021) roll up into 13 3M EAPG types, such as 2—Significant Procedure and 3—Medical Visit. The 3M EAPGs also roll up into 61 categories, such as 15—Radiologic Procedures and 62—Diabetes Mellitus.

In addition, each 3M EAPG is assigned to a service line aligned with the inpatient service lines defined by the 3M 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.