An Episode of Care (EOC) is the bundle of Arkansas Medicaid-covered health care services provided to treat a particular condition from the list below for a given length of time. EOCs are based on data from two main sources: 1) paid claims processed according to standard Medicaid fee-for-service reimbursements, and 2) data submitted through AHIN (Advanced Health Information Network), a Provider Portal utilized when key data are not available through claims.
For each EOC, providers submit claims and will continue to be reimbursed according to established fee schedules. A Principal Accountable Provider (PAP) is identified for each EOC through claims data. PAPs are defined as providers who have the greatest potential to influence treatment decisions, cost, and quality of care within each type of EOC. PAPs share in savings or excess costs of an EOC determined by the average cost per valid EOC and performance on quality/outcome measures as compared to peers.
Special Note Regarding ICD-10 Coding
On October 1, 2015, the United States transitioned from the International Classification of Diseases – Ninth Revision (ICD-9) to ICD-10 as the medical code set for medical diagnoses and inpatient hospital procedures. Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes will continue in use for outpatient, ambulatory, and office-based procedure coding. Arkansas Medicaid’s Fee-for-Service provider reimbursement system has implemented the new ICD-10 code set into the Medicaid Management Information System (MMIS). The Episodes of Care (EOC) provider incentive program uses MMIS claims data in its processing; therefore, EOCs also utilize the new diagnosis coding standard.
Because EOCs are retrospective by design (based on after-the-fact paid claims data submissions) and include a 90-day claims “run-out” period following the closing date of each episode, provider reports reflecting the newly adopted ICD-10 code set will not be published until April 30, 2016. Nevertheless, Episodes of Care will recognize and utilize the newly adopted ICD-10 coding requirement for any claim dated on or after October 1, 2015.As the EOC's quality assurance team receives, reviews, and verifies claims containing ICD-10 codes, new Episode Summary and Episode Code set documents will be available and published on this website. Accurate coding and submission of claims are always appropriate; EOCs are not designed to alter a provider’s coding practice. EOC code sets are not intended to serve as coding guidelines, as providers are professionally responsible for coding to reflect patients’ diagnoses and treatments provided with the greatest possible accuracy.