Enhanced Ambulatory Patient Grouping (EAPG)

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This is an update from how bilateral services are currently billed on the UB-04 for BCBSND. Under EAPGs, providers will be required to bill bilateral services on one line with modifier 50. Services billed bilaterally will continue to receive 150% of the fee schedule under EAPGs.

No. Ambulance, Home Health and Hospice services will continue to flow through our current outpatient logic (not EAPG logic). All other services (including ASC services) will flow through the EAPG logic.

Yes, there will be services carved out of EAPGs. Please refer to the EAPG carveout fee schedule.

These services should be billed on the same outpatient claim as other outpatient services provided on the same day. These lines will be paid based on the carveout fee schedule rather than based on the EAPG fee schedule. Providers should refer to the EAPG listings file available through 3M for a crosswalk of HCPCS/CPT codes to EAPGs.

Please note, there will only be one rate on the EAPG carveout fee schedule for all peer groups—BCBSND will not have different rates for these codes on the carveout fee schedule based on peer group.

Yes, a grouper can be purchased through 3M. BCBSND’s base rates and weights will be loaded into this grouper software as well as any carveout rates.

Yes, lessor of charge logic will apply to EAPG claims at the visit level.

A “visit” is all services on the same date of service. BCBSND encourages providers to bill all outpatient services for the same date of service on one claim in order for claims to process correctly. Providers are still able to bill multiple dates of service on one claim (e.g., therapy services) under EAPGs.

Exception: Emergency Room , Observation, Recovery room - if services within these types of claims span more than one day, all services will be considered one visit.

No, that logic will be sun-setted once claims transition to EAPGs. As a result of this, BCBSND will no longer be publishing Attribute Indicators on fee schedules.

Yes, correct coding edits (i.e., NCCI) will continue to apply to all outpatient claims.

Observation will be packaged with a significant procedure EAPG, but separate payment will be allowed for observation with a medical visit EAPG. If Observation is billed without a medical visit or significant procedure then it will be assigned EAPG 999 and therefore no payment will be made.

Significant Procedure Discounting is reducing the standard payment rate for an EAPG to recognize that the cost of a second procedure in a visit is less than the cost of providing the procedure by itself. Types of significant procedure discounting include multiple procedure discounting, terminated procedure and bilateral discounting. Bilateral services are to be billed on one line with modifier 50 appended.

Same Significant Procedure Consolidation happens when multiple occurrences of the same significant procedure EAPG are present on a claim. The highest weighted significant procedure EAPG will be paid in full and any subsequent occurrences of that same significant procedure EAPG will be consolidated and receive no payment. BCBSND applies Same Significant Procedure Consolidation (SSP) for Significant Procedure type (2) and Diagnostic type (25) to versions 3.14 and 3.16. SSP will not apply to versions 3.17 and subsequent versions.

Ancillary discounting applies to ancillaries within the same EAPG. With ancillary discounting, the 3M grouper software reads the first ancillary line billed on the claim and assumes that to be the ancillary line paid in full, all other ancillary lines with the same EAPG are then tagged in the grouper and will therefore discount at 50%. (Please note that this does not apply to ancillary services that will package with surgical or medical visit EAPGs.)

Yes. Ancillary services are packaged when billed with a significant procedure or medical visit EAPG. The Ancillary Packaging List will be published with the EAPG fee schedule in the Online Fee Schedule portal.

EAPG fee schedules will continue to be posted to the Online Fee Schedule portal. This will include any EAPG carveout rates as well.

Separate Procedures: Modifier 59 must be used to bypass payment consolidation for separate procedures. Modifiers XE, XS, XP and XU will not bypass consolidation for Separate Procedures.

Distinct Medical Visits: Modifiers 25, XE, XS, XP and XU can be used to identify distinct medical visits for separate payment when reported with a significant procedure. The X modifiers are not required so you can choose to always use modifier 25 in this scenario.

The Initial search of a claim in Remittance Viewer in Availity Essentials will display like this: Click to view

Clicking the Line Item Control # will open a side panel on the right that will display the EAPG code: Click to view

The EAPG weight set was developed, in cooperation with 3M, utilizing the claims submitted by providers for a 12-month base period, applying the applicable Cost to Charge Ratios on the individual provider Medicare Cost Report for the 12-month base period to determine the average cost to provide each covered service. The individual EAPG weight is based on the average cost for that EAPG code in comparison to the average cost for all the EAPGs. For example – EAPG 574 has an average cost of $163.09, the average cost of all EAPGs is $133.46. Based on this, the weight assigned to EAPG 574 would be 1.222 (163.09/133.46).