Enhanced Ambulatory Patient Groups (EAPG)

ForwardHealth uses the Enhanced Ambulatory Patient Group (EAPG) classification system to calculate pricing for outpatient hospital claims. The groups used in the EAPG system categorize the amount and type of resources used in various outpatient visits. Under the EAPG classification system, reimbursement for outpatient hospital services is based on the quantity and type of services provided. The system ensures that both low- and high-cost services are reimbursed appropriately.

The EAPG reimbursement methodology applies to fee-for-service members enrolled in BadgerCare Plus, Wisconsin Medicaid, and the Wisconsin Chronic Disease Program.

EAPG was implemented for fee-for-service claims on April 1, 2013, and extended to HMO encounters on January 1, 2015. ForwardHealth continues to publish rate-per-visit information for county jail reference. Currently, ForwardHealth uses EAPG software version 3.9 and updates the EAPG grouper version with each new rate year.

ForwardHealth Updates

2013-07	Enhanced Ambulatory Patient Groups Implementation and Additional Training Dates, 2/1/13
2012-55	Implementation of the Enhanced Ambulatory Patient Groups Reimbursement Methodology, 10/5/12
2012-53	Revenue Codes Exempt from the Procedure Code Requirement for Outpatient Hospital Services, 10/2/12
2012-26	Appropriate Modifiers and Most Specific Diagnosis Codes Required on Outpatient Hospital Claims, 6/25/12
2012-24	Procedure Codes Required with All Revenue Codes on Outpatient Hospital Claims, 6/6/12

Provider Trainings

The following presentations were developed for HMO EAPG implementation. However, most of the content is applicable to both fee-for-service claims and HMO encounters.

EAPG Rates and Weights

Current and archived EAPG rates and weights are available.

Additional Information

EAPG Definitions Manual Request Form
Providers with questions regarding fee-for-service EAPG claims may e-mail them to vedseapgsupport@wisconsin.gov
- Questions should not be sent in a secured format (e.g., Zix Email Encryption), because these messages cannot be opened for security reasons.
HMOs with questions regarding EAPG encounters may e-mail them to vedshmosupport@wisconsin.gov
- Questions should not be sent in a secured format (e.g., Zix Email Encryption) because these messages cannot be opened for security reasons.
Provider Services: (800) 947-9627

Frequently Asked Questions

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Wisconsin Department of Health Services

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