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Enhanced Ambulatory Patient Grouping Questions and Answers

Enhanced Ambulatory Patient Grouping Questions and Answers

The Enhanced Ambulatory Patient Groups (EAPG) system was implemented by ForwardHealth on April 1, 2013, to classify and calculate reimbursement for outpatient hospital services. Under the EAPG system, ForwardHealth reimburses hospital providers for outpatient services based on the quantity and type of services they provide. The new system ensures that both low- and high-cost services are reimbursed appropriately.

Refer to the October 2012 ForwardHealth Update (2012-55), titled "Implementation of Enhanced Ambulatory Patient Groups Reimbursement Methodology" for more information.

Questions are grouped into the following categories:


General EAPG Questions

Question Number:196
Posting Date08/29/13
Question:I work for a company that pays claims on behalf of inmates at local jails in Wisconsin. We reprice the claims based on your state's Medicaid rates. Where might I find the appropriate EAPG number that belongs with a specific CPT code?
Answer:Refer to question 290 for information on obtaining an EAPG Definitions Manual. For rate year 2013, companies that use the Medicaid rate to price inmate claims should use the hospital per-visit Medicaid rates available for HMO use. These rates can be found on the ForwardHealth Portal under "Rates Effective 2/1/2013." In the future, ForwardHealth will be setting a global rate specifically for this purpose.


Question Number:197
Posting Date12/14/12
Question:Which ForwardHealth members' claims will be processed through EAPG?
Answer:All hospital claims for outpatient hospital services for members enrolled in BadgerCare Plus, Medicaid, and the Wisconsin Chronic Disease Program will be processed using the EAPG system. The Wisconsin Well Woman Program is not affected.


Question Number:198
Posting Date12/14/12
Question:What providers and services are impacted by EAPG?
Answer:All claims for outpatient hospital services submitted by Medicaid-enrolled hospitals, including critical access and acute care hospitals, will be processed using the EAPG system. Claims from providers who are not Medicaid-enrolled hospitals, such as rural health clinics, federally qualified health centers, home health agencies, hospices, and end-stage renal disease providers, will not be reimbursed using the EAPG system.


Question Number:199
Posting Date12/14/12
Question:Does a hospital need to purchase the 3M coding module for EAPG billing in order to be paid correctly under EAPG reimbursement?
Answer:No. Hospitals are welcome to purchase the software, but it would be used for reimbursement planning and verification purposes only.


Billing Questions

Question Number:289
Posting Date08/29/13
Question:We are a critical access hospital. We also have hospital-based clinics that are designated as rural health clinics. Do we need to send our claims using the new EAPG billing methodology since we are paid per diem rates? If not, do we still need to report the EAPG on our claims? I am asking this because the software we would need to do this would be costly.
Answer:

You will continue to bill services on the UB-04 Claim Form or using the 837 Health Care Claim: Institutional transaction as you have in the past, taking note of what is considered a "visit" (refer to the October 2012 ForwardHealth Update [2012-55], titled "Implementation of the Enhanced Ambulatory Patient Groups Reimbursement Methodology").

You do not need to purchase any EAPG software for your claims to process and be priced using the EAPG pricing method. You also do not enter any EAPG-related information on the claim. ForwardHealth will process and price your claim using the EAPG software and report the EAPG back to you on your 835 remittance.

Effective for dates of service on and after April 1, 2013, you will no longer be paid at per diem rates. Your claims will process using the EAPG pricing methodology, which uses EAPG rates.


Question Number:290
Posting Date08/29/13
Question:Is there a crosswalk that providers can access on the ForwardHealth Portal to help find the appropriate EAPG number associated with a HCPCS code?
Answer:To receive a listing of all the services (procedure codes) grouped under each EAPG, you will need to contact 3M and complete a form to request a free copy of the 3M EAPG Definitions Manual. Only the first copy of the manual is free. A copy of the form is also available on the EAPG page of the ForwardHealth Portal; however, please contact 3M at 1-800-435-7776 for assistance. If you purchased the provider version of the EAPG software, the EAPG Definitions Manual is included in the purchase price.


Question Number:291
Posting Date12/14/12
Question:A member has IV therapy 3 times a week and on one of those days, the member is seen in ER. How should this be billed?
Answer:ForwardHealth recommends billing each visit on a separate claim; in the example above, this would result in four separate claims. When billing for services on the date of service (DOS) that includes the ER visit, providers are asked to include condition code G0 (the letter "G" and the digit zero) on the second claim submitted for that DOS to differentiate the visits. Billing the services this way helps ensure the provider is reimbursed appropriately, receiving an access payment for each visit. Refer to Update 2012-55 for more information.


Question Number:292
Posting Date12/14/11
Question:What is ForwardHealth's definition or criteria for "related" visits?
Answer:When the initial visit matches the primary diagnosis of a subsequent visit(s), these are referred to as related visits.

Question Number:293
Posting Date12/14/12
Question:When submitting two different claims for unrelated services provided on the same date of service (DOS), how is the primary claim identified?
Answer:A primary claim does not need to be identified. ForwardHealth recommends including condition code G0 on the second claim submitted, which allows the system to differentiate one service from another on the same DOS.


Question Number:294
Posting Date12/14/12
Question:How should physical therapy, occupational therapy, speech and language pathology, and behavioral health be billed?
Answer:Current ForwardHealth policy states that these services must be billed on the 1500 Health Insurance Claim Form or the 837 Health Care Claim: Professional transaction in order to be eligible for reimbursement. If these services appear on one or more claim details on an outpatient claim, those details would be denied. If the claim consists only of these services, the entire claim would be denied.


Question Number:295
Posting Date12/14/12
Question:Should we continue use the 1500 Health Insurance Claim Form when billing for lab services?
Answer: If you are Medicaid-enrolled as an independent lab and are performing services as an independent lab, you should bill on a professional claim. If the laboratory services are provided as part of the outpatient hospital visit, the lab services should be included on the outpatient hospital claim and would be reimbursed at the maximum allowable fee.


Question Number:296
Posting Date12/14/12
Question:How will the EAPG system treat "not otherwise classified" HCPCS codes?
Answer:The EAPG system will assign an EAPG and group "not otherwise classified" HCPCS procedure codes as it would any other code.


Question Number:297
Posting Date12/14/12
Question:Does Medicaid prefer that providers use the RT/LT modifiers or the 50 modifier?
Answer:Either may be used. When both the RT and LT modifiers are used, they must be listed on separate details.


Question Number:298
Posting Date12/14/12
Question:Say a patient comes in and has emergency surgery, a procedure that ForwardHealth considers "inpatient-only." The patient dies during the surgery, never having been admitted. How should the provider handle this?
Answer:If this claim denies after a provider has billed for a situation such as the one described, ForwardHealth recommends the provider contact his or her professional representative so the rep can assist with the processing. A situation like this will require special handling of the claim.


Question Number:299
Posting Date12/14/12
Question:If we bill an infusion code (i.e., 96365-96368, 96379, 96360-96361), will ForwardHealth require the presence of a drug on the claim? If so, do you want a drug under revenue code 250 with no HCPCS procedure code or revenue code 636 with a procedure code?
Answer:Providers should bill infusion codes according to common billing practices, regardless of the implementation of the EAPG reimbursement methodology.


National Correct Coding Initiative Questions

Question Number:397
Posting Date12/14/12; Revised: 08/29/13
Question:Does ForwardHealth use the same version of the National Correct Coding Initiative (NCCI) as Medicare?
Answer:For outpatient hospital claims, ForwardHealth uses a required subset of the NCCI regulations followed by Medicare. General information regarding NCCI edits for Medicaid is located at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html.


Question Number:398
Posting Date12/14/12
Question:Is there an appeals process for NCCI?
Answer:Yes, the appeals process for NCCI is outlined in Update 2012-55.


Question Number:399
Posting Date12/14/12
Question:If a provider receives a denial for a Medically Unlikely Edit, can he or she resubmit using modifier 91? How will the EAPG system handle Medicare crossover claims with modifier 91?
Answer:ForwardHealth does not recognize modifier 91, but will recognize modifier 59. On crossover claims, modifier 91 should not hinder processing of the claim. However, providers may need to resubmit or adjust the claim with modifier 59 in some cases.


Rate Questions

Question Number:497
Posting Date08/29/13
Question:Will EAPG affect out-of-state hospital outpatient payment rates? They are reimbursed at a percent of allowable charge, correct?
Answer:

EAPG pricing applies to all hospitals and institutes for mental disease, regardless of the provider being in-state, border status, or out of state. EAPG pricing replaces rate-per-day pricing and percent of charge.

The rates calculated for in-state, border status, and out-of-state providers for EAPG claim pricing will be different from the rates that were calculated and used for rate-per-day and percent-of-charge pricing. EAPG is a completely different pricing methodology with its own set of weights and provider rates.



Question Number:498
Posting Date12/14/12
Question:Which cost reports are used to calculate base rates?
Answer:The most recent audited cost reports are used to make these calculations. However, if the most recent audited cost report is more than five years old, providers may appeal the rate and request that ForwardHealth use a more recent unaudited cost report.


Question Number:499
Posting Date12/14/12
Question:Will every hospital have the same outpatient rate?
Answer:Critical access hospitals will have their own provider-specific rates, but all other hospitals will have the same rate. Current and past provider rates are available on the ForwardHealth Portal.

Reimbursement Questions

Question Number:588
Posting Date08/29/13
Question:We are a hospital-based clinic. Will Medicare crossover visits be reimbursed using the EAPG reimbursement methodology?
Answer:Medicare crossovers are subject to the EAPG reimbursement methodology, but only for claims billed from provider type 01 (hospitals) and 58 (institutes for mental disease).


Question Number:589
Posting Date08/29/13
Question:When I look up a CPT code in the EAPG Definitions Manual it shows the EAPG number. Am I supposed to times the EAPG by our provider rate? If not, where do I find the weight associated with the EAPG?
Answer:The EAPG is just a code under which similar services are grouped. The weight associated with the EAPG can be found in a spreadsheet attached to the EAPG Page on the ForwardHealth Portal. To estimate your payment, multiply the weight associated with the EAPG times your provider rate.


Question Number:590
Posting Date12/14/12
Question:How will this new reimbursement method affect us; will we get paid more or less?
Answer:The Department of Health Services considers EAPG a budget-neutral implementation. This reimbursement method allows Medicaid to pay appropriately and fairly, but is not expected to generate additional revenue for the state. Providers may see a change in reimbursement based on the services they provide.


Question Number:591
Posting Date12/14/12
Question:Is reimbursement handled differently for services submitted on a professional claim (e.g., 1500 Health Insurance Claim Form or 837 Health Care Claim: Professional transaction)?
Answer:Yes. EAPG only applies to outpatient hospital claims and does not apply to professional billing. To determine reimbursement for professional services, refer to the maximum fee schedule applicable for the service area in question.


Question Number:592
Posting Date12/14/12
Question:How is pay for performance (P4P) affected by EAPG?
Answer:EAPG will have no independent impact on P4P withholding; ForwardHealth will continue to withhold funds for P4P.


Question Number:593
Posting Date12/14/12
Question:Is there reimbursement for revenue codes that are exempt?
Answer:Although exempt revenue codes may not be separately reimbursed, the costs are included for purposes of rate setting, so it's important these services are billed.


Question Number:594
Posting Date12/14/12
Question:When a detail pays $0, how does a provider know from the 835 Health Care Claim Payment/Advice transaction whether it's packaged or invalid?
Answer:Providers will need to download the .TXT (text) format of the Remittance Advice (RA) to view the EAPG associated with the detail. The .TXT format RA may be downloaded from the provider's secure account on the Portal.


Question Number:595
Posting Date12/14/12
Question:Will "not otherwise classified" codes have a lower reimbursement?
Answer:Reimbursement is determined by taking the provider-specific base rate and multiplying it by the EAPG-assigned weight. The reimbursement of these codes will depend on the weights assigned.


Question Number:596
Posting Date12/14/12
Question:How are hospice and home health services affected by EAPG?
Answer:There is no change to hospice and home health services reimbursement.


Question Number:597
Posting Date12/14/12
Question:If a patient was admitted to the ER on 3/31/13 and leaves on 4/1/13, how will the hospital be reimbursed?
Answer:The hospital will be reimbursed according to the payment methodology effective on the day the member came in, so in this example, the hospital would be reimbursed using the rate-per-visit method.


Question Number:598
Posting Date12/14/12
Question:If a service is provided as an outpatient hospital service but Medicare considers it "inpatient only" while Medicaid does not, what should the provider do?
Answer:The provider should submit the service on a straight Medicaid claim with the appropriate Medicare disclaimer code.


Question Number:599
Posting Date12/14/12
Question:If a claim is discounted by other insurance but is not reimbursable under Medicaid, should the provider still bill Wisconsin Medicaid?
Answer:All claims for an eligible member on an eligible date of service should be submitted to ForwardHealth.
 
 
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