3M™ Enhanced Ambulatory Patient Groups (EAPGs) are specifically designed for today’s complex ambulatory environment.This methodology captures the current changes in clinical practice and resource use to provide a broader, more inclusive classification of outpatient care.
Using the 3M EAPG methodology, providers can more easily manage the complexity of outpatient claims, identify cost recovery opportunities, and improve both outpatient coding compliance and reimbursement.
3M 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 3M EAPG share similar clinical characteristics, resource use and costs. EAPGs are not applicable to services of physicians and other professionals typically paid separately.
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 Solventum 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:
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, 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 3M EAPGs, such as the CMS APCs.
The 3M EAPGs are integrated with other Solventum patient classification methodologies.
Solventum 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 Solventum products:
Licensees of the 3M EAPG methodology has access to the following documents on the Solventum customer support website:
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.
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 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:
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 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.