Episode grouper for Medicare (EGM)
What is an episode grouper for Medicare (EGM)?
An EGM is a proprietary software program that organizes claims data by episodes of care, typically linked to a diagnosis. The episode of care encompasses all services provided to care for an illness or injury during a predefined period of time.
The Centers for Medicare & Medicaid Services (CMS) developed the EGM software application, designing it to read through Medicare administrative claims data and assigns services and their Medicare payments to episodes of care. The episodes of care may be defined by diagnosis codes (e.g., stroke) or procedure codes (e.g., pacemaker insertion).
What is the benefit of EGM?
EGM accounts for Medicare costs and utilizations using categories that make sense to clinicians. This allows for those responsible for healthcare systems to evaluate items such as the Medicare cost of a specific disease over time or the types of providers involved in caring for patients who have a certain condition.
Additionally, episode grouping allows for the comparison of estimated Medicare costs for a specific diagnosis or procedure based on various patient attributes. For example, episode grouping allows a health system to compare how patient cohorts within a particular geographical region have higher costs than other patients with similar clinical reports.
EGM can also highlight the areas where spending patterns can be improved, whether that is within a physician’s practice or by reducing the need for a specific procedure across all healthcare facilities.