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Home Provider Claims and Payment Enhanced Ambulatory Patient Grouping (EAPG)
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EAPG Reference Guide

Diabetic Education

  • Report Diabetic Education services using revenue code 942 and HCPCS codes G0108 and G0109.
  • Payment for these services will package into any significant outpatient procedures provided on the same date.
  • You may continue to bill Medical Nutrition Therapy using CPT codes 97802, 97803, 97804, or 99078.

Durable Medical Equipment

  • Submit outpatient durable medical equipment (DME) claims as a professional claim using your DME NPI (National Provider Identifier).
  • DME is not reimbursable when billed under the hospital's acute NPI.

EAPG Billing Requirements

  • Do not submit date spans on the claim line.
  • The unit of measure for the EAPG methodology is a calendar date so the EAPG grouper reads only the "from" date on the claim.
  • If a claim line is date spanned, reimbursement will be reduced.
  • Services billed under revenue code 45X (Emergency Room), 71X (Recovery Room), or 762 (Observation Bed) will appropriately group as one visit regardless of the dates submitted.

Electronic Claims with 450-Line Maximum

  • Separate electronic claims with more than 450 lines into two claims before submission.

Inpatient-Only Surgeries

  • There are specific surgeries Wellmark requires be performed in an inpatient setting.
  • When one of these surgeries is performed and billed as an outpatient procedure, Wellmark will deny the entire claim.
  • If you would like the claim reviewed, please submit the operative report and other medical documentation with a Provider Inquiry form.

Outpatient Hospital Modifiers

  • 50 modifier — Wellmark will accept the 50 modifier on one claim line with one unit of service. This modifier will process at 150 percent of Wellmark's Maximum Allowable Fee (MAF) when appropriate. Wellmark uses the CMS bilateral indicators found in the Physician Fee Schedule file to determine correct billing.
  • 51 modifier — Wellmark will process surgeries that are applicable to multiple surgery reduction at 50 percent of Wellmark's MAF. These are defined by the Enhanced Ambulatory Patient Groupings (EAPGs) as multiple significant procedures. EAPG will be used to process claims with services provided on and after October 1, 2010.
  • Reduced services (52 modifier) and discontinued procedures prior to anesthesia (73 modifier) will continue to process at 50 percent of Wellmark's MAF.
  • 59 modifier — Wellmark is no longer using the 59 modifier to determine payment within Wellmark's EAPG Grouper. Providers should continue to use the 59 modifier when appropriate.

National Drug Codes Submission

  • National Drug Codes (NDCs) provide the information Wellmark needs to process unlisted drug codes, eliminating the need for you to provide additional details, such as dosage, drug name, and strength.
  • Please include the NDC with revenue code 636 and an unlisted drug code (such as HCPCS code J3490).

 Dialysis Services

  • Under the EAPG payment methodology, Wellmark limited the submission of CPT code 90999 to Hemodialysis services.  This CPT code should only be submitted with revenue code 0821.  Claims containing CPT code 90999 submitted with revenue codes other than 0821 will be denied.

Current Procedural Terminology © 2011 American Medical Association. All Rights Reserved.

 



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