Presented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications

Presented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications

Complete and correct coding of claims will become more important, and will have an effect on claim payment. The EAPG grouper/pricer specific to Illinois Medicaid will assign the EAPGs to the claim lines and calculate the payment. Hospitals may choose to purchase the 3M EAPG grouping software which would allow them to project revenue.

Outpatient hospital services reimbursed through the EAPG PPS shall include: Surgical services. odiagnostic and therapeutic services. Emergency department services. Observation services. Psychiatric treatment services. 550 EAPG groups

Each CPT/HCPCS procedure code on a claim line is assigned to the appropriate EAPG at the line level. Each EAPG has an assigned relative weight. Illinois Medicaid will be using the National weights that are utilized by 3M. This relative weight is adjusted by the various payment mechanisms as applicable such as discounting, packaging and consolidation. The adjusted relative weight is multiplied by a conversion factor or base rate to yield the EAPG payment amount. Illinois Medicaid will develop the base rates.

There will be an EAPG Listing that will replace the APL.

The 3 levels of reimbursement will be eliminated. The minimum number of observation hours that can be billed is 1. Revenue Code 762 must be billed with one of the following HCPCS Codes: 99218, 99219, 99220, 99234, 99235 and 99236 in addition to G0378. Observation services that span more than two days, can be billed electronically.

Policy remains the same: If a patient receives emergency department or observation services and is then admitted as an inpatient on the same date, department policy allows separate billing of the emergency room charge or observation services on an outpatient claim. Any ancillary services must be shown on the inpatient claim.

Policy remains the same: Certain outpatient services provided on multiple dates of service can be submitted on one institutional claim form. A series claim must contain an appropriate series revenue code and series-billable procedure code from the Ambulatory Procedures Listing/EAPG Listing.

This edit/error description will be eliminated. U29 (Multiple APL Groups Not Valid For Series Bill) Outpatient series bills cannot contain procedures from more than one APL group. Contact a hospital billing consultant for assistance. With the implementation of the EAPGs, multiple APL Groups can be billed on series claim.

This policy will be eliminated. Enter Value Code 24 and the number of hospital departments visited for the treatment episode. The number of departments visited x $57.50. With the implementation of the EAPGs, Medicare crossover claims will be billed & priced based on the EAPG system.

New Illinois Medicaid requirement with the implementation of the EAPG system: Required when claim involves outpatient visits. Enter the ICD-9-CM diagnosis code that describes the patient s reason for visit.

Exceptions to all-inclusive EAPG PPS rate. A hospital may bill separately for: Professional services of a physician who provided direct patient care in conjunction with an APL/EAPG. Chemotherapy services provided in conjunction with radiation therapy services. Physical rehabilitation, occupational or speech therapy services provided in conjunction with an APL/EAPG reimbursed service.

Medicaid Primary PT, OT & ST billed on the professional side, HFS 1443/837P under the hospital s feefor-service name and NPI. Medicare Crossover Claims Current Policy: All therapy services billed on the institutional side, UB-04/837I. This policy is under review by HFS.

Existing Edits/Error Code Descriptions will need to be revised and some eliminated.

This policy remains the same: Revenue Code 450 must be billed with one of the following HCPCS Codes: 99284, 99285, 99291, G0383, or G0384 Revenue Code 456 must be billed with one of the following HCPCS Codes: 99282, 99283, G0381, or G0382 Revenue Code 451 must be billed with the following HCPCS Code: 99281 or G0380

This policy remains the same: Psychiatric Clinic Type A services must be billed with one of the following HCPCS Codes: 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90870, 90875, 90876, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215.

Psychiatric Clinic Type B services must be billed with the following HCPCS Code: S9480

EAPG standardized amount The standardized amount established by the Department as the basis for EAPG conversion factor differs based on the provider type. Critical access hospital EAPG standardized amount.

For critical access hospitals, the EAPG standardized amounts are determined separately for each critical access hospital such that: Simulated EAPG payments using outpatient base period paid claim data plus payments as defined in Section 148.456 net of tax costs are equal to: Estimated costs of outpatient base period claims data with a rate year cost inflation factor applied.

Procedures that are typically performed in an ambulatory setting are divided into three types of procedures in the EAPG System: significant procedures, ancillary tests and procedures Incidental procedure

Significant Procedures: Normally scheduled and constitutes the reason for the visit. Example: excision of skin lesion, stress tests Ancillary Tests & Procedures: Ordered by the primary physician to assist in patient diagnosis or treatment. Example: 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

Patients who receive medical treatment but do not have a significant procedure performed during the visit. Medical patients are described using the diagnoses. The primary diagnosis is the only diagnosis that is required.

EAPGs define medical visits based on primary diagnosis codes. Examples: CPT Code: 99283 Diagnosis: 4139 = EAPG Assigned: 598 CPT Code: 99283 Diagnosis: 7871 = EAPG Assigned: 624 All other types of 3M EAPGs are assigned based on the HCPCS codes reported as line item services.

If no significant procedure is performed, that episode of care may be considered a medical visit when other criteria are met such as the presence of an E/M CPT code. Visits without a significant procedure or a medical visit indicator (E/M CPT code) are considered ancillary only visits. Under EAPG, the payment is dependent on the diagnosis codes and the procedure codes submitted.

Multiple EAPGs may be assigned per visit. Each line assigned an EAPG. Processes claims with multiple dates of service. The use of modifiers. EAPG 999 identifies services that cannot be assigned to any valid EAPG. For example, EAPG 999 would be given to claim details that lack a HCPCS code.

The Unassigned EAPG (999) can result for any of the following reasons: User Ignored Inpatient Procedure Invalid Procedure Code Code not used by EAPGs Invalid Dx for Medical Visit E-code Dx for Medical Visit Non-covered care or settings Invalid date (out of range) Invalid Procedure Direct Per Diem code w/o qualifying Pdx Observation condition error DAO condition error Gender Unknown No HCPCS code (Revenue Code Only)

Significant Procedure Medical Visit Ancillary

Examples: Musculoskeletal system procedures Pulmonary system procedures

EAPGs EAPG Type Description Count 1 Per Diem 4 2 Significant Procedure 148 21 Physical Therapy & Rehab 10 22 Mental Health & Counseling 15 23 Dental Procedure 23 24 Radiologic Procedure 27 25 Other Diagnostic Procedure 15 Subtotal Sign Px 238 3 Medical Visit 190 4 Ancillary 67 5 Incidental 3 6 Drug 23 7 DME 25 8 Unassigned 3 TOTAL 553

HCPCS Description EAPG EAPG Type EAPG Category 20808 Replantation hand complete 20816 Replantation digit complete 20822 Replantation digit complete 20900 Removal of bone for graft 20920 Removal of fascia for graft 20930 Sp bone algrft morsel add-on 20931 Sp bone algrft struct add-on 993 8 99 993 8 99 34 2 3 31 2 3 14 2 1 490 5 30 221 2 11

Patients may be assigned, and paid for, more than one EAPG per visit Each claim line in a visit is evaluated for an EAPG; a single visit may have multiple EAPGs. The logic in the grouper will assign each line (CPT/HCPCS code) to the appropriate EAPG at the line level. All CPT/HCPCS codes claimed for a visit (same date of service) should be included on the claim.

Some EAPGs may consolidate or package and pay zero at the line level and some EAPGs may be discounted. What are the discounting rules? Multiple unconsolidated significant procedures and multiple unpackaged ancillaries are discounted.

Packaging Consolidation Modifiers Never pay Observation

There are multiple types of packaging logic used within the grouping system. The result is that fewer line items receive separate payment. EAPG Standard Logic includes: Consolidation (significant procedure consolidation) Ancillary packaging

There is a Uniform Packaging List that is used for packaging. If the EAPG is not on the listing or there is no significant procedure or medical visit on claim, the EAPG is paid separately. If ancillary service is provided alone, no packaging is done.

EAPG EAPG Description 373 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 Description 413 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

The EAPG system uses three methods for grouping different services provided into a single payment unit: ancillary packaging, significant procedure consolidation and discounting

Ancillary Packaging Ancillary packaging refers to the inclusion of certain ancillary services into the EAPG payment for a significant procedure or medical visit. Ancillary services that are inexpensive or frequently provided and are clinically expected to be a routine part of the specific procedure or medical visit are packaged.

CPT Code EAPG Assigned EAPG Description Action 45385 137 Therapeutic colonoscopy Include in payment 88304 390 Level I pathology Package 82947 402 Basic chemistry tests Package 84233 399 Level II endocrinology tests Include in payment 93000 413 Cardiogram Package

Consolidation Consolidation refers to the collapsing of significant procedures into a single EAPG for payment purposes.

Consolidation There are two types of significant procedure consolidation. The first type is same significant procedure EAPG consolidation which occurs when two significant procedure HCPCS codes group to the same EAPG. The second type is clinically related significant procedure consolidation.

Revenue Code 0450 CPT 99282 Revenue Code 0450 CPT Code 11000 Revenue Code 0450 CPT Code 15783

Code Final EAPG Total Payment 99282 (medical visit indicator) 11000 (Level 1 Skin Debridement) 15783 (Level 1 Skin Debridement) 491 $0.00 6 $285.10 6 $0.00

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.

Example of Clinical Significant Procedure: Revenue Code 0360 CPT Code 30630 EAPG: 254 Total Payment: $1,341.25 Revenue Code 0360 CPT Code 30905 EAPG: 12 Total Payment: $0.00

Discounting Discounting refers to a reduction in the payment for an EAPG. Discounting can occur on repeated ancillary procedures that group to the same EAPG or on an unrelated significant procedure performed multiple times.

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%

So in the following example, the only services that would pay would be 35476, 36120, 72193 & 75978 because the other ancillary services are not on the APL/EAPG.

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 $3,886.90 36120 Establish access to artery 280 Sign Px 5.3728 50.00% Discounted $1,484.93 72193 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 $99.99 85610 Prothrombin time 406 Ancill 0.00 0.00% Packaged $0.00 75790 Visualize A-V shunt 474 Ancill 2.9696 100.00% Full payment $820.74 75978 Repair venous blockage 474 Ancill 1.4848 50.00% Discounted $410.37 Total $6,792.65

The EAPG grouper uses some modifiers to affect payment as well as a list of procedures that are only paid when provided in an inpatient setting. Other features provide payers with options to define payment policies such as never pay procedures.

CPT/HCPCS Modifiers The grouper recognizes CPT/HCPCS modifiers that may impact pricing. The modifiers used with EAPGs vary depending on the payer s choice.

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 nonrelated 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%

HFS will accept all of these modifiers.

This grouper functionality may be used by payers to enforce services not covered or other payment policies. For example, cosmetic surgery or services paid outside the EAPG payment system.

It provides the payer with a selection for identifying the minimum observation hours (reported as units) criteria required to assign the Ancillary Observation EAPG 450 to HCPCS code G0378. Illinois Medicaid has determined that the minimum number of observation hours will be 1.

Ancillary Observation EAPG 450 HCPCS Code G0378 1) Receives full payment if there is also a Medical Visit Indicator (MVI) EAPG 491 2) E & M Codes 99201-99205; 99211-99214, 99281-99285, G0463

Billing Example: Revenue Code 0450 CPT Code 99281(Medical Visit Indicator) Revenue Code 0762 HCPCS Code G0378 (Observation) Revenue Code 0762 CPT Code 99218 Units => 1 Receives Full Payment for both services.

Medical visits describe patients who receive medical treatment but do not have a significant procedure performed during the visit. EAPGs define medical visits based on primary diagnosis codes.

1) If G0378 is billed with units less than 1 hour, the line groups to EAPG 999 Unassigned. 2) If G0378 occurs with a significant procedure, then it is packaged.

If G0378 occurs with Observation Visit Indicator (OVI), EAPG 492, then the line will group to either EAPG 500, 501 or 502. Observation Visit Indicator (OVI) G0379 (direct admit to observation); OR observation E/M 99217-99220; 99224-99226; 99234-99236

Billing Example: Revenue Code 0762 HCPCS Code G0378 (Observation) Revenue Code 0762 HCPCS Code G0379 (Observation Visit Indicator) The Revenue Code line with G0378 will be grouped to EAPG 500, 501 or 502 and will not be paid separately.

If no MVI, no OVI and no significant procedure occur, then the line will group to EAPG 999 Unassigned.

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 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

Other data fields Age Gender Disposition Some condition and value codes Units of service Charges Line item dates of service

3M EAPG has very limited editing; 3M provides separate editing that is available with the 3M applications. These edits may be turned off as a whole or individually.

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