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Enhanced Ambulatory Patient Groupings (EAPG)

Effective October 1, 2010, Wellmark Blue Cross and Blue Shield will reimburse most outpatient facility services using Enhanced Ambulatory Patient Groupings (EAPG) payment methodology.

The payment change will affect outpatient services submitted by the following Wellmark contracting providers:

• hospitals
• ambulatory surgery centers
• renal dialysis centers
• freestanding substance abuse facilities

Please check this site periodically for EAPG information as it becomes available.

Learn About

• Claim Requirements and Processing Changes for Outpatient Claims, Blue Ink issues:
  • Admission Hour: page 8, August 2010 
  • Ambulance Services: page 5, April 2010 
  • Bundled Services: page 5, April 2010 
  • Dates and Times: page 12, December 2009  
  • Diabetic Education: page 8, August 2010 
  • Diagnostic Services – Iowa Only Change: page 15, June 2010  
  • Durable Medical Equipment: page 8, August 2010 
  • Electronic Claims 450-Line Maximum: page 12, December 2009 
  • iCAP Edits and Secondary Payer Claims: page 6, April 2010 
  • Inpatient-Only Procedures: page 12, December 2009 ; page 6, April 2010 
  • Modifiers: page 6, April 2010 ; page 9, June 2010 ; page 13, October 2010 
  • National Drug Codes: page 13, December 2009 ; page 9, June 2010 
  • PCR - Locating Definitions of EAPG Codes: page 6, October 2010 
  • Recovery Room Services to Group; page 4, February 2011 
  • Revenue and CPT or HCPCS Requirements: page 13, December 2009 and page 8, August 2010  
  • Single Outpatient Claim for One Date of Service: page 4, February 2011
• Common Coding Concerns 
• EAPG Questions and Answers (April 2011)
• New Message Codes (revised November 2010)  
• Observation Claim Processing (April 2011)
• Qualifying Diagnosis Codes for Mental Health and Substance Abuse Per Diem Services  
• Revenue Codes Requiring CPT/HCPCS Codes (revised November 2010)  

Quick Notes (Outpatient and Inpatient Information included)

• May 2011 
• April 2011 

Patient Education

• Paying Greater Than Charge 

EAPG Webinar Documents

• April 16, 2009 – Basics of New Outpatient Payment System 
• April 28, 2009 – Refresher and Policy Update 
• December 17, 2009 – Billing Requirements and Financial Impact Analysis 
  • Q&A from December 17, 2009, Webinar 
• September 17, 2010 - EAPG Implementation Reminders, Updates  
  • Q&A from September 17, 2010, Webinar