Solventum™ Enhanced Ambulatory Patient Groups (EAPGs) Classification System

Solventum EAPGs are designed to reflect the resources used in an ambulatory visit. These include nursing and technician time, drugs, supplies, ancillary tests, equipment, treatment time, etc. Patients in each Solventum EAPG share similar clinical characteristics, resource use and costs. EAPGs are not applicable to services of physicians and other professionals typically paid separately.

Solventum EAPGs are used by payers, hospitals, ASCs, other providers, government agencies and researchers. Payers often turn to Solventum EAPGs as the basis for an outpatient prospective payment system. Providers combine Solventum EAPGs with Solventum payer-specific reimbursement calculation software to forecast and verify expected reimbursement. Payers, providers, government agencies and researchers rely on Solventum 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 Solventum EAPG patient classification methodology can bring value:

• Appropriate incentives. Implementing a Solventum 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. Solventum makes available reimbursement calculation software so providers can predict and verify expected payment using a specific payer’s Solventum EAPG pricing policy.
  
  
• Public reporting. Because Solventum EAPGs define an outpatient visit, they are useful in public reporting and other comparisons across hospitals and states.
  
  
• Quality comparisons. Solventum EAPGs are used in defining Solventum™ Potentially Preventable Emergency Department Visits (PPVs) Classification System and Solventum™ Potentially Preventable Services (PPS) Classification System, which are important measures of effectiveness in managing population health.
  
  
• Clinical insight. Hospitals, other providers, government agencies, payers and researchers use Solventum 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 Solventum 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.

Solventum 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 Solventum 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, Solventum 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).

Solventum also makes available outpatient reimbursement calculation software for national payers that do not use Solventum EAPGs, such as the CMS APCs.

The Solventum EAPGs are integrated with other Solventum patient classification methodologies.

Solventum has aligned the service line definitions between Solventum EAPGs for outpatient care and the Solventum™ All Patient Refined Diagnosis Related Groups (APR DRGs) Classification System for inpatient care. This alignment allows analysis of charges, costs, payments and utilization by service line across both inpatient and outpatient settings.

The Solventum PPV methodology uses Solventum EAPGs to define potentially preventable emergency department visits. A common example is Solventum EAPG 562 Infections of Upper Respiratory Tract and Otitis Media.

The Solventum PPS compares services with its indicated diagnoses to identify potentially preventable ancillary services. For example, Solventum EAPG 450 observation is considered a potentially preventable service when the diagnosis is other family psycho/social circumstances.

Solventum EAPGs are used to define certain Solventum™ Patient-focused Episodes (PFEs) Classification System. For example, Solventum EAPG 086 (Pacemaker and Other Cardiovascular Device Insertion and Replacement) triggers Patient Focused Episode 0860 (Pacemaker Insertion and Replacement).

The Solventum EAPGs are available in the following Solventum products:

• Solventum™ 360 Encompass™ System
• Solventum™ Coding and Reimbursement System (CRS)
• Solventum™ Clinical Documentation Improvement Solution
• Solventum™ Reimbursement Calculation Software
• Solventum™ Core Grouping Software (CGS)
• Solventum™ Grouper Plus Content Services (GPCS)
• Solventum™ Data-to-Action (DTA) Solution
• Solventum™ Intelligent Data Asset (IDA)
• Solventum EAPG mainframe version

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

• Solventum EAPG Methodology Overview
• Solventum EAPG Definitions Manual
• Solventum EAPG Summary of Changes
• Solventum EAPG Installation and User's Guide for IBM® Mainframe Platforms
• Solventum EAPG Code Listings (Microsoft® Excel file)
• Solventum EAPG National Weights (Microsoft® Excel file)

The unit of analysis is an outpatient visit. All the data required to assign Solventum 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 Solventum 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.

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 Solventum. 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, Solventum developed the Solventum EAPGs which were first released in 2007 and have since become the industry standard alternative to APCs.

Solventum 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 Solventum EAPG policies provide important incentives for efficiency and cost control:

• Ancillary packaging: Refers to the inclusion of related ancillary services into the Solventum 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 Solventum EAPGs into a single Solventum EAPG to determine payment. For example, when a claim includes both Solventum EAPG 3 Level I Skin Incision and Drainage, Debridement, Destruction, Other Related Px and Solventum EAPG 16 Simple Wound Repair and Treatment, then Solventum EAPG 16 is consolidated into Solventum EAPG 3. Solventum EAPG 16 is shown on the claim but with zero payment.
  
  
• Discounting: Refers to a reduction in the Solventum 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 Solventum clinicians, data analysts, programmers and economists. The Solventum proprietary logic is available for licensees to view in an online definition’s manual.

Each year, Solventum calculates and releases a set of statistics for each Solventum EAPG based on our analysis of large national data sets. These statistics include a relative weight for each Solventum EAPG. The relative weight reflects the average resource use for a patient in that Solventum EAPG relative to a subset of common ambulatory services, please note that payers and other users of the Solventum EAPG methodology are responsible for using relative weights appropriate for their populations.

Solventum EAPGs can be rolled up into broader categories. The 648 Solventum EAPGs in version 3.16 (2021) roll up into 13 Solventum EAPG types, such as 2—Significant Procedure and 3—Medical Visit. The Solventum EAPGs also roll up into 61 categories, such as 15—Radiologic Procedures and 62—Diabetes Mellitus.