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The purpose of this bulletin is to notify hospitals and ASCs about the delay in updating the 3M All-Patient Refined Diagnosis-Related Group (APR-DRG) and Enhanced Ambulatory Patient Group (EAPG) versions and weights for state fiscal year 2023 (SFY23). This bulletin serves as an update to the July 13, 2022, bulletins titled “Hospital Reimbursement – Effective July 1, 2022” and “Ambulatory Surgical Center Reimbursement – Effective July 1, 2022.”

Inpatient APR-DRG Version & Weights Update

DMAS was required to implement version 38 of the 3M APR-DRG grouper and rebase the APR-DRG weights, effective with discharges on or after July 1, 2022. However, implementation of the new grouper version and weights has been delayed. DMAS will notify providers when the changes have been implemented via blast email. Claims paid prior to the implementation of the updated grouper and weights will be automatically reprocessed when the updates are completed.

The Virginia-specific DRG weights, as well as other inpatient reimbursement parameters, are available on the DMAS web site at https://www.dmas.virginia.gov/for-providers/rates-and-rate-setting/hospital-rates/.

Outpatient & ASC EAPG Version & Weights Update

DMAS was required to implement version 3.16 of the 3M EAPG grouper and rebase the EAPG weights, effective July 1, 2022. Implementation of the new grouper version and weights has been delayed. DMAS will notify providers when the changes have been implemented via blast email. Claims paid prior to the implementation of the updated grouper and weights will be automatically reprocessed when the updates are completed.

The new EAPG weights and base rates are available on the DMAS web site at https://www.dmas.virginia.gov/for-providers/rates-and-rate-setting/outpatient-eapg/.

Outpatient & ASC EAPG Addition of a 4^th Digit Update

The DMAS 3M EAPG claims processing system does not currently allow for capturing the EAPG codes with more than three (3) digits. DMAS is in the process of implementing a temporary fix until the grouper can accept four (4) digits. The temporary fix will only apply to EAPG codes that are four (4) digits long and will only show up on remittance advices (RA) or the EDI 835. Please continue to follow standard billing practices and use standard billing codes. While the temporary fix is in place, an alpha numeric EAPG code will show up on your remittance advice or EDI 835 using the key below.                                              

For a list of the affected EAPG codes and the associated temporary fix codes for EAPG Grouper Version 3.16 as of July 1, 2022, please see the table below. EAPG codes that are three (3) digits or less will remain the same.

The agency will identify and automatically reprocess claims with four (4) digits that did not pay for dates of service on or after July 1, 2022, until the temporary fix was implemented.  When the payment system is fully updated to accept four (4) digit codes, all EAPG codes will show up normally on the RA or EDI 835.

Please contact the DMAS help line at 1-800-552-8627 if you have any questions concerning hospital reimbursement.