APR-DRG Assignmentlni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2014FS/fsDrg.pdf · APR-DRG...
Transcript of APR-DRG Assignmentlni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2014FS/fsDrg.pdf · APR-DRG...
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG Assignment
Effective for Dates of Service on or After
July 1, 2014
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L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 1
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
Column
Title
APR-DRG
Number
SOI
APR-DRG
Description
High
Outlier
Threshold
Dollar Amount
PD
NC
Relative
Weight
The costs necessary to qualify as a High
Outlier APR-DRG-paid case.
APR-DRG relative weight.
APR-DRG is not covered by L&I
Number
Rehabilitation APR-DRG
Surgical APR-DRG
REHAB
SURG
DRG Type
LV
NC
Costs minus High Outlier Threshold equals Outlier
Payment
Column Values Value Definitions
APR-DRG ASSIGNMENT
FIELD KEY:
MED
Not Covered
PSYCH
APR-DRGs from version 31.0 by 3M Health Information
SystemsNumber
Descriptions supplied by 3M Health Information Systems
Chemical Dependency APR-DRGCHEM DEP
Number 1 - Minor; 2 - Moderate; 3 - Major; 4 - Extreme
Medical APR-DRG
APR-DRG is not covered by L&I
Psychiatric APR-DRG
APR-DRG does not qualify for outlier payments
APR-DRG is not covered by L&I
Indicates the APR-DRG relative weight;
Payment can be calculated by multiplying the APR-DRG
relative weight by the Hospital base rate.
Low volume APR-DRG.
Payment can be calculated by multiplying the APR-DRG
type Per Diem rate by the length of stay
Severity of Illness
All Patient Refined Diagnosis Related Group
Number
Column Description
Indicates DRG Type or coverage status.
Abbreviated APR-DRG description.
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 2
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
Column
Title Column Description
Avg. LOS
Paid Using
APR-DRGPayment calculated by multiplying the APR-DRG relative
weight by the Hospital base rate
Per DiemPayment calculated by multiplying the Per Diem amount
by the length of stay
How payment of the APR-DRG will be
calculated
Not Covered APR-DRG is not covered by L&I
Low Outlier
Threshold
Dollar Amount
Column Values
The costs necessary to qualify as a Low
Outlier APR-DRG-paid case
Value Definitions
FIELD KEY: APR-DRG ASSIGNMENT (continued)
Expected length of stay for conditions falling
within the APR-DRG.
The average length of stay for the APR-DRG.
On cases paid using the relative weight times the base
The highest cost necessary to qualify as a low outlier.
APR-DRG does not qualify for outlier payments
APR-DRG is not covered by L&I
Days
PD
NC
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 3
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 4
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
001 1 LIVER TRANS &/OR INTEST TRANS Surg LV PD PD 24.0 PER DIEM
001 2 LIVER TRANS &/OR INTEST TRANS Surg LV PD PD 24.0 PER DIEM
001 3 LIVER TRANS &/OR INTEST TRANS Surg LV PD PD 24.0 PER DIEM
001 4 LIVER TRANS &/OR INTEST TRANS Surg LV PD PD 24.0 PER DIEM
002 1 HEART &/OR LUNG TRANSPLANT Surg LV PD PD 17.0 PER DIEM
002 2 HEART &/OR LUNG TRANSPLANT Surg LV PD PD 17.0 PER DIEM
002 3 HEART &/OR LUNG TRANSPLANT Surg LV PD PD 37.8 PER DIEM
002 4 HEART &/OR LUNG TRANSPLANT Surg LV PD PD 37.8 PER DIEM
003 1 BONE MARROW TRANSPLANT Surg LV PD PD 24.0 PER DIEM
003 2 BONE MARROW TRANSPLANT Surg LV PD PD 24.0 PER DIEM
003 3 BONE MARROW TRANSPLANT Surg LV PD PD 24.0 PER DIEM
003 4 BONE MARROW TRANSPLANT Surg LV PD PD 24.0 PER DIEM
004 1 TRACH W MV 96+ W EXTN PROC OR ECMO Surg 13.4716 241,088.08 13,572.16 33.4 APR-DRG
004 2 TRACH W MV 96+ W EXTN PROC OR ECMO Surg 13.4716 241,088.08 13,572.16 33.4 APR-DRG
004 3 TRACH W MV 96+ W EXTN PROC OR ECMO Surg 13.4716 241,088.08 13,572.16 33.4 APR-DRG
004 4 TRACH W MV 96+ W EXTN PROC OR ECMO Surg 13.4716 241,088.08 13,572.16 33.4 APR-DRG
005 1 TRACH W MV 96+ WO EXTN PROC Surg LV PD PD 35.0 PER DIEM
005 2 TRACH W MV 96+ WO EXTN PROC Surg LV PD PD 35.0 PER DIEM
005 3 TRACH W MV 96+ WO EXTN PROC Surg LV PD PD 35.0 PER DIEM
005 4 TRACH W MV 96+ WO EXTN PROC Surg LV PD PD 35.0 PER DIEM
006 1 PANCREAS TRANSPLANT Surg LV PD PD 10.0 PER DIEM
006 2 PANCREAS TRANSPLANT Surg LV PD PD 10.0 PER DIEM
006 3 PANCREAS TRANSPLANT Surg LV PD PD 12.0 PER DIEM
006 4 PANCREAS TRANSPLANT Surg LV PD PD 12.0 PER DIEM
020 1 CRANIOTOMY FOR TRAUMA Surg 5.8473 95,067.41 4,246.98 10.2 APR-DRG
020 2 CRANIOTOMY FOR TRAUMA Surg 5.8473 95,067.41 4,246.98 10.2 APR-DRG
020 3 CRANIOTOMY FOR TRAUMA Surg 5.8473 95,067.41 4,246.98 10.2 APR-DRG
020 4 CRANIOTOMY FOR TRAUMA Surg 5.8473 95,067.41 4,246.98 10.2 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 5
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
021 1 CRANIOTOMY EXC FOR TRAUMA Surg 1.5499 32,044.61 2,064.14 4.1 APR-DRG
021 2 CRANIOTOMY EXC FOR TRAUMA Surg 2.7761 43,153.04 2,077.89 5.3 APR-DRG
021 3 CRANIOTOMY EXC FOR TRAUMA Surg 5.8473 95,067.41 4,246.98 10.2 APR-DRG
021 4 CRANIOTOMY EXC FOR TRAUMA Surg LV PD PD 10.2 PER DIEM
022 1 VENTRICULAR SHUNT PROC Surg LV PD PD 4.0 PER DIEM
022 2 VENTRICULAR SHUNT PROC Surg LV PD PD 4.0 PER DIEM
022 3 VENTRICULAR SHUNT PROC Surg LV PD PD 4.0 PER DIEM
022 4 VENTRICULAR SHUNT PROC Surg LV PD PD 4.0 PER DIEM
023 1 SPINAL PROCEDURES Surg 3.4641 48,529.04 1,686.45 5.3 APR-DRG
023 2 SPINAL PROCEDURES Surg 3.4641 48,529.04 1,686.45 5.3 APR-DRG
023 3 SPINAL PROCEDURES Surg 3.4641 48,529.04 1,686.45 5.3 APR-DRG
023 4 SPINAL PROCEDURES Surg 3.4641 48,529.04 1,686.45 5.3 APR-DRG
024 1 EXTRACRANIAL VASCULAR PROC Surg LV PD PD 3.0 PER DIEM
024 2 EXTRACRANIAL VASCULAR PROC Surg LV PD PD 3.0 PER DIEM
024 3 EXTRACRANIAL VASCULAR PROC Surg LV PD PD 3.0 PER DIEM
024 4 EXTRACRANIAL VASCULAR PROC Surg LV PD PD 3.0 PER DIEM
026 1 OTH NERVOUS SYST & RELAT PROC Surg LV PD PD 1.8 PER DIEM
026 2 OTH NERVOUS SYST & RELAT PROC Surg 1.3088 30,041.03 1,452.42 2.0 APR-DRG
026 3 OTH NERVOUS SYST & RELAT PROC Surg 1.4023 31,122.52 1,556.27 2.3 APR-DRG
026 4 OTH NERVOUS SYST & RELAT PROC Surg 1.4023 31,122.52 1,556.27 2.3 APR-DRG
040 1 SPINAL DISORDERS & INJURIES Med 0.7360 17,726.58 681.97 3.8 APR-DRG
040 2 SPINAL DISORDERS & INJURIES Med 0.7360 17,726.58 681.97 3.8 APR-DRG
040 3 SPINAL DISORDERS & INJURIES Med 0.7360 17,726.58 681.97 3.8 APR-DRG
040 4 SPINAL DISORDERS & INJURIES Med 0.7360 17,726.58 681.97 3.8 APR-DRG
041 1 NERVOUS SYSTEM MALIGNANCY Med LV PD PD 7.0 PER DIEM
041 2 NERVOUS SYSTEM MALIGNANCY Med LV PD PD 7.0 PER DIEM
041 3 NERVOUS SYSTEM MALIGNANCY Med LV PD PD 7.0 PER DIEM
041 4 NERVOUS SYSTEM MALIGNANCY Med LV PD PD 7.0 PER DIEM
042 1 DEGENERATV NERV SYS DIS EXC MS Med LV PD PD 6.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 6
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
042 2 DEGENERATV NERV SYS DIS EXC MS Med LV PD PD 6.0 PER DIEM
042 3 DEGENERATV NERV SYS DIS EXC MS Med LV PD PD 6.0 PER DIEM
042 4 DEGENERATV NERV SYS DIS EXC MS Med LV PD PD 6.0 PER DIEM
043 1 MULT SCLEROSIS/OTH DEMYELIN DX Med LV PD PD 5.0 PER DIEM
043 2 MULT SCLEROSIS/OTH DEMYELIN DX Med LV PD PD 5.0 PER DIEM
043 3 MULT SCLEROSIS/OTH DEMYELIN DX Med LV PD PD 5.0 PER DIEM
043 4 MULT SCLEROSIS/OTH DEMYELIN DX Med LV PD PD 5.0 PER DIEM
044 1 INTRACRANIAL HEMORRHAGE Med LV PD PD 5.5 PER DIEM
044 2 INTRACRANIAL HEMORRHAGE Med LV PD PD 5.5 PER DIEM
044 3 INTRACRANIAL HEMORRHAGE Med LV PD PD 6.0 PER DIEM
044 4 INTRACRANIAL HEMORRHAGE Med LV PD PD 6.0 PER DIEM
045 1 CVA W INFARCT Med LV PD PD 4.6 PER DIEM
045 2 CVA W INFARCT Med LV PD PD 4.6 PER DIEM
045 3 CVA W INFARCT Med LV PD PD 4.6 PER DIEM
045 4 CVA W INFARCT Med LV PD PD 4.6 PER DIEM
046 1 NONSPEC CVA & PRECEREB OCCL Med LV PD PD 3.6 PER DIEM
046 2 NONSPEC CVA & PRECEREB OCCL Med LV PD PD 3.6 PER DIEM
046 3 NONSPEC CVA & PRECEREB OCCL Med LV PD PD 3.6 PER DIEM
046 4 NONSPEC CVA & PRECEREB OCCL Med LV PD PD 3.6 PER DIEM
047 1 TRANSIENT ISCHEMIA Med LV PD PD 2.0 PER DIEM
047 2 TRANSIENT ISCHEMIA Med LV PD PD 2.0 PER DIEM
047 3 TRANSIENT ISCHEMIA Med LV PD PD 2.0 PER DIEM
047 4 TRANSIENT ISCHEMIA Med LV PD PD 2.0 PER DIEM
048 1 PERIPH CRANIAL AUTON NERV DX Med 0.5791 17,726.58 590.97 4.0 APR-DRG
048 2 PERIPH CRANIAL AUTON NERV DX Med 0.5791 17,726.58 590.97 4.0 APR-DRG
048 3 PERIPH CRANIAL AUTON NERV DX Med 0.7026 17,726.58 590.97 9.0 APR-DRG
048 4 PERIPH CRANIAL AUTON NERV DX Med 0.7026 17,726.58 590.97 9.0 APR-DRG
049 1 BACT & TUBERCULOUS NERV INFECT Med LV PD PD 10.0 PER DIEM
049 2 BACT & TUBERCULOUS NERV INFECT Med LV PD PD 10.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 7
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
049 3 BACT & TUBERCULOUS NERV INFECT Med LV PD PD 10.0 PER DIEM
049 4 BACT & TUBERCULOUS NERV INFECT Med LV PD PD 10.0 PER DIEM
050 1 NON-BACT NERV INFECT EXC VM Med LV PD PD 5.0 PER DIEM
050 2 NON-BACT NERV INFECT EXC VM Med LV PD PD 5.0 PER DIEM
050 3 NON-BACT NERV INFECT EXC VM Med LV PD PD 5.0 PER DIEM
050 4 NON-BACT NERV INFECT EXC VM Med LV PD PD 5.0 PER DIEM
051 1 VIRAL MENINGITIS Med LV PD PD 2.9 PER DIEM
051 2 VIRAL MENINGITIS Med LV PD PD 2.9 PER DIEM
051 3 VIRAL MENINGITIS Med LV PD PD 2.9 PER DIEM
051 4 VIRAL MENINGITIS Med LV PD PD 2.9 PER DIEM
052 1 NONTRAUMA STUPOR & COMA Med LV PD PD 2.9 PER DIEM
052 2 NONTRAUMA STUPOR & COMA Med LV PD PD 3.0 PER DIEM
052 3 NONTRAUMA STUPOR & COMA Med LV PD PD 3.1 PER DIEM
052 4 NONTRAUMA STUPOR & COMA Med LV PD PD 5.5 PER DIEM
053 1 SEIZURE Med 0.5431 17,726.58 994.04 2.7 APR-DRG
053 2 SEIZURE Med 0.5431 17,726.58 994.04 2.7 APR-DRG
053 3 SEIZURE Med 0.5491 17,726.58 597.17 3.3 APR-DRG
053 4 SEIZURE Med 0.5491 17,726.58 597.17 3.3 APR-DRG
054 1 MIGRAINE & OTHER HEADACHE Med LV PD PD 2.6 PER DIEM
054 2 MIGRAINE & OTHER HEADACHE Med LV PD PD 3.0 PER DIEM
054 3 MIGRAINE & OTHER HEADACHE Med LV PD PD 4.7 PER DIEM
054 4 MIGRAINE & OTHER HEADACHE Med LV PD PD 4.7 PER DIEM
055 1 HEAD TRAUMA W COMA >1 HR/HEMOR Med 1.1473 17,726.58 954.50 2.6 APR-DRG
055 2 HEAD TRAUMA W COMA >1 HR/HEMOR Med 1.1473 17,726.58 954.50 2.6 APR-DRG
055 3 HEAD TRAUMA W COMA >1 HR/HEMOR Med 1.1473 17,726.58 954.50 2.6 APR-DRG
055 4 HEAD TRAUMA W COMA >1 HR/HEMOR Med 1.1473 17,726.58 954.50 2.6 APR-DRG
056 1 BRAIN CONTUSION/LACERATION Med 0.5678 17,726.58 657.31 1.7 APR-DRG
056 2 BRAIN CONTUSION/LACERATION Med 0.5689 17,726.58 590.97 2.3 APR-DRG
056 3 BRAIN CONTUSION/LACERATION Med 0.6555 17,726.58 648.02 2.4 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 8
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
056 4 BRAIN CONTUSION/LACERATION Med 0.7171 17,726.58 821.59 3.3 APR-DRG
057 1 CONCUSSION/CLOSED SKULL FRACT Med LV PD PD 1.7 PER DIEM
057 2 CONCUSSION/CLOSED SKULL FRACT Med LV PD PD 1.7 PER DIEM
057 3 CONCUSSION/CLOSED SKULL FRACT Med LV PD PD 1.7 PER DIEM
057 4 CONCUSSION/CLOSED SKULL FRACT Med LV PD PD 1.7 PER DIEM
058 1 OTH DISORDERS NERVOUS SYS Med 0.6502 17,726.58 590.97 2.1 APR-DRG
058 2 OTH DISORDERS NERVOUS SYS Med LV PD PD 3.7 PER DIEM
058 3 OTH DISORDERS NERVOUS SYS Med LV PD PD 3.7 PER DIEM
058 4 OTH DISORDERS NERVOUS SYS Med 2.2419 24,142.16 1,533.64 4.0 APR-DRG
070 1 ORBITAL PROCEDURES Surg 1.2647 17,726.58 1,052.17 1.4 APR-DRG
070 2 ORBITAL PROCEDURES Surg 1.2647 17,726.58 1,052.17 1.4 APR-DRG
070 3 ORBITAL PROCEDURES Surg 1.2647 17,726.58 1,052.17 1.4 APR-DRG
070 4 ORBITAL PROCEDURES Surg 1.2647 17,726.58 1,052.17 1.4 APR-DRG
073 1 EYE PROCEDURES EXCEPT ORBIT Surg 0.6769 17,726.58 768.14 1.6 APR-DRG
073 2 EYE PROCEDURES EXCEPT ORBIT Surg LV PD PD 2.0 PER DIEM
073 3 EYE PROCEDURES EXCEPT ORBIT Surg LV PD PD 2.2 PER DIEM
073 4 EYE PROCEDURES EXCEPT ORBIT Surg LV PD PD 3.0 PER DIEM
080 1 ACUTE MAJOR EYE INFECTIONS Med LV PD PD 3.0 PER DIEM
080 2 ACUTE MAJOR EYE INFECTIONS Med LV PD PD 3.0 PER DIEM
080 3 ACUTE MAJOR EYE INFECTIONS Med LV PD PD 7.9 PER DIEM
080 4 ACUTE MAJOR EYE INFECTIONS Med LV PD PD 7.9 PER DIEM
082 1 EYE DISORDERS EXC MAJOR INFECT Med LV PD PD 1.2 PER DIEM
082 2 EYE DISORDERS EXC MAJOR INFECT Med LV PD PD 2.0 PER DIEM
082 3 EYE DISORDERS EXC MAJOR INFECT Med LV PD PD 3.0 PER DIEM
082 4 EYE DISORDERS EXC MAJOR INFECT Med LV PD PD 3.2 PER DIEM
089 1 MAJ CRANIAL/FACIAL BONE PROC Surg LV PD PD 5.0 PER DIEM
089 2 MAJ CRANIAL/FACIAL BONE PROC Surg LV PD PD 5.0 PER DIEM
089 3 MAJ CRANIAL/FACIAL BONE PROC Surg LV PD PD 5.0 PER DIEM
089 4 MAJ CRANIAL/FACIAL BONE PROC Surg LV PD PD 5.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 9
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
090 1 MAJ LARYNX & TRACHEA PROC Surg LV PD PD 12.5 PER DIEM
090 2 MAJ LARYNX & TRACHEA PROC Surg LV PD PD 12.5 PER DIEM
090 3 MAJ LARYNX & TRACHEA PROC Surg LV PD PD 30.0 PER DIEM
090 4 MAJ LARYNX & TRACHEA PROC Surg LV PD PD 30.0 PER DIEM
091 1 OTH MAJ HEAD & NECK PROC Surg LV PD PD 5.8 PER DIEM
091 2 OTH MAJ HEAD & NECK PROC Surg LV PD PD 5.8 PER DIEM
091 3 OTH MAJ HEAD & NECK PROC Surg LV PD PD 6.8 PER DIEM
091 4 OTH MAJ HEAD & NECK PROC Surg LV PD PD 6.8 PER DIEM
092 1 FACIAL BONE PROC EXC MAJOR Surg LV PD PD 3.0 PER DIEM
092 2 FACIAL BONE PROC EXC MAJOR Surg LV PD PD 3.0 PER DIEM
092 3 FACIAL BONE PROC EXC MAJOR Surg LV PD PD 3.0 PER DIEM
092 4 FACIAL BONE PROC EXC MAJOR Surg LV PD PD 3.0 PER DIEM
093 1 SINUS & MASTOID PROC Surg LV PD PD 3.0 PER DIEM
093 2 SINUS & MASTOID PROC Surg LV PD PD 3.0 PER DIEM
093 3 SINUS & MASTOID PROC Surg LV PD PD 3.7 PER DIEM
093 4 SINUS & MASTOID PROC Surg LV PD PD 3.7 PER DIEM
095 1 CLEFT LIP & PALATE REPAIR Surg LV PD PD 2.0 PER DIEM
095 2 CLEFT LIP & PALATE REPAIR Surg LV PD PD 2.0 PER DIEM
095 3 CLEFT LIP & PALATE REPAIR Surg LV PD PD 2.0 PER DIEM
095 4 CLEFT LIP & PALATE REPAIR Surg LV PD PD 2.0 PER DIEM
097 1 TONSIL & ADENOID PROC Surg LV PD PD 1.9 PER DIEM
097 2 TONSIL & ADENOID PROC Surg LV PD PD 2.0 PER DIEM
097 3 TONSIL & ADENOID PROC Surg LV PD PD 3.0 PER DIEM
097 4 TONSIL & ADENOID PROC Surg LV PD PD 3.6 PER DIEM
098 1 OTH EAR NOSE MOUTH THROAT PROC Surg 0.8829 17,726.58 920.50 1.9 APR-DRG
098 2 OTH EAR NOSE MOUTH THROAT PROC Surg LV PD PD 2.0 PER DIEM
098 3 OTH EAR NOSE MOUTH THROAT PROC Surg LV PD PD 3.0 PER DIEM
098 4 OTH EAR NOSE MOUTH THROAT PROC Surg LV PD PD 9.0 PER DIEM
110 1 EAR NOSE MOUTH THROAT MALIG Med LV PD PD 9.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 10
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
110 2 EAR NOSE MOUTH THROAT MALIG Med LV PD PD 9.0 PER DIEM
110 3 EAR NOSE MOUTH THROAT MALIG Med LV PD PD 9.0 PER DIEM
110 4 EAR NOSE MOUTH THROAT MALIG Med LV PD PD 9.0 PER DIEM
111 1 VERTIGO & OTHER LABYRINTH DX Med LV PD PD 3.0 PER DIEM
111 2 VERTIGO & OTHER LABYRINTH DX Med LV PD PD 3.0 PER DIEM
111 3 VERTIGO & OTHER LABYRINTH DX Med LV PD PD 3.0 PER DIEM
111 4 VERTIGO & OTHER LABYRINTH DX Med LV PD PD 3.0 PER DIEM
113 1 INFECTIONS OF UP RESP TRACT Med LV PD PD 4.9 PER DIEM
113 2 INFECTIONS OF UP RESP TRACT Med LV PD PD 4.9 PER DIEM
113 3 INFECTIONS OF UP RESP TRACT Med LV PD PD 6.0 PER DIEM
113 4 INFECTIONS OF UP RESP TRACT Med LV PD PD 6.0 PER DIEM
114 1 DENTAL & ORAL DISEASE & INJURY Med LV PD PD 1.9 PER DIEM
114 2 DENTAL & ORAL DISEASE & INJURY Med LV PD PD 1.9 PER DIEM
114 3 DENTAL & ORAL DISEASE & INJURY Med 4.6167 49,220.91 590.97 2.6 APR-DRG
114 4 DENTAL & ORAL DISEASE & INJURY Med 4.6167 49,220.91 590.97 2.6 APR-DRG
115 1 OTH EAR NOSE MOUTH THROAT CRAN DXMed LV PD PD 1.5 PER DIEM
115 2 OTH EAR NOSE MOUTH THROAT CRAN DXMed LV PD PD 2.3 PER DIEM
115 3 OTH EAR NOSE MOUTH THROAT CRAN DXMed LV PD PD 3.0 PER DIEM
115 4 OTH EAR NOSE MOUTH THROAT CRAN DXMed LV PD PD 7.0 PER DIEM
120 1 MAJ RESPIRATORY & CHEST PROC Surg LV PD PD 4.8 PER DIEM
120 2 MAJ RESPIRATORY & CHEST PROC Surg LV PD PD 4.8 PER DIEM
120 3 MAJ RESPIRATORY & CHEST PROC Surg 1.9783 20,449.22 1,645.80 14.0 APR-DRG
120 4 MAJ RESPIRATORY & CHEST PROC Surg 1.9783 20,449.22 1,645.80 14.0 APR-DRG
121 1 OTH RESPIRATORY & CHEST PROC Surg LV PD PD 3.4 PER DIEM
121 2 OTH RESPIRATORY & CHEST PROC Surg LV PD PD 4.2 PER DIEM
121 3 OTH RESPIRATORY & CHEST PROC Surg LV PD PD 7.0 PER DIEM
121 4 OTH RESPIRATORY & CHEST PROC Surg LV PD PD 12.0 PER DIEM
130 1 RESPIRATORY DX W MV 96+ HRS Med 1.2376 30,044.85 1,906.97 4.5 APR-DRG
130 2 RESPIRATORY DX W MV 96+ HRS Med 1.2376 30,044.85 1,906.97 4.5 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 11
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
130 3 RESPIRATORY DX W MV 96+ HRS Med LV PD PD 15.6 PER DIEM
130 4 RESPIRATORY DX W MV 96+ HRS Med LV PD PD 15.6 PER DIEM
131 1 CYSTIC FIBROSIS-PULM DX Med LV PD PD 10.0 PER DIEM
131 2 CYSTIC FIBROSIS-PULM DX Med LV PD PD 10.0 PER DIEM
131 3 CYSTIC FIBROSIS-PULM DX Med LV PD PD 10.0 PER DIEM
131 4 CYSTIC FIBROSIS-PULM DX Med LV PD PD 10.0 PER DIEM
132 1 BPD & OTH CHRONIC RESP DIS Med LV PD PD 4.5 PER DIEM
132 2 BPD & OTH CHRONIC RESP DIS Med LV PD PD 4.5 PER DIEM
132 3 BPD & OTH CHRONIC RESP DIS Med LV PD PD 15.6 PER DIEM
132 4 BPD & OTH CHRONIC RESP DIS Med LV PD PD 15.6 PER DIEM
133 1 PULMONARY EDEMA & RESP FAIL Med 0.4320 17,726.58 590.97 2.9 APR-DRG
133 2 PULMONARY EDEMA & RESP FAIL Med 0.5963 17,726.58 701.85 3.1 APR-DRG
133 3 PULMONARY EDEMA & RESP FAIL Med 0.7271 17,726.58 777.50 3.6 APR-DRG
133 4 PULMONARY EDEMA & RESP FAIL Med LV PD PD 4.0 PER DIEM
134 1 PULMONARY EMBOLISM Med 0.6400 17,726.58 800.03 4.1 APR-DRG
134 2 PULMONARY EMBOLISM Med 0.6400 17,726.58 800.03 4.1 APR-DRG
134 3 PULMONARY EMBOLISM Med 0.6400 17,726.58 800.03 4.1 APR-DRG
134 4 PULMONARY EMBOLISM Med 0.6400 17,726.58 800.03 4.1 APR-DRG
135 1 MAJOR CHEST & RESP TRAUMA Med 0.5775 17,726.58 590.97 2.3 APR-DRG
135 2 MAJOR CHEST & RESP TRAUMA Med 0.5775 17,726.58 590.97 2.3 APR-DRG
135 3 MAJOR CHEST & RESP TRAUMA Med 0.6341 17,726.58 621.12 3.1 APR-DRG
135 4 MAJOR CHEST & RESP TRAUMA Med 0.6341 17,726.58 621.12 3.1 APR-DRG
136 1 RESPIRATORY MALIGNANCY Med 0.9353 17,726.58 778.04 6.0 APR-DRG
136 2 RESPIRATORY MALIGNANCY Med 0.9353 17,726.58 778.04 6.0 APR-DRG
136 3 RESPIRATORY MALIGNANCY Med 0.9356 17,726.58 778.04 6.0 APR-DRG
136 4 RESPIRATORY MALIGNANCY Med 0.9353 17,726.58 778.04 6.0 APR-DRG
137 1 MAJOR RESPIRATORY INFECTIONS Med LV PD PD 4.8 PER DIEM
137 2 MAJOR RESPIRATORY INFECTIONS Med LV PD PD 4.8 PER DIEM
137 3 MAJOR RESPIRATORY INFECTIONS Med 1.0077 17,726.58 838.31 10.0 APR-DRG
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Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
137 4 MAJOR RESPIRATORY INFECTIONS Med 1.0077 17,726.58 838.31 10.0 APR-DRG
138 1 BRONCHIOLITIS & RSV PNEUM Med LV PD PD 2.8 PER DIEM
138 2 BRONCHIOLITIS & RSV PNEUM Med LV PD PD 2.9 PER DIEM
138 3 BRONCHIOLITIS & RSV PNEUM Med LV PD PD 3.0 PER DIEM
138 4 BRONCHIOLITIS & RSV PNEUM Med LV PD PD 4.0 PER DIEM
139 1 OTHER PNEUMONIA Med 0.5469 17,726.58 590.97 2.0 APR-DRG
139 2 OTHER PNEUMONIA Med 0.5469 17,726.58 590.97 2.0 APR-DRG
139 3 OTHER PNEUMONIA Med 0.5838 17,726.58 647.37 3.3 APR-DRG
139 4 OTHER PNEUMONIA Med 0.5838 17,726.58 647.37 3.3 APR-DRG
140 1 CHRONIC OBSTRUCTIVE PULM DIS Med 0.5205 17,726.58 634.89 3.5 APR-DRG
140 2 CHRONIC OBSTRUCTIVE PULM DIS Med 0.5205 17,726.58 634.89 3.5 APR-DRG
140 3 CHRONIC OBSTRUCTIVE PULM DIS Med 0.5205 17,726.58 634.89 3.5 APR-DRG
140 4 CHRONIC OBSTRUCTIVE PULM DIS Med 0.5205 17,726.58 634.89 3.5 APR-DRG
141 1 ASTHMA Med 0.3875 17,726.58 590.97 1.3 APR-DRG
141 2 ASTHMA Med 0.3875 17,726.58 590.97 1.3 APR-DRG
141 3 ASTHMA Med LV PD PD 3.0 PER DIEM
141 4 ASTHMA Med LV PD PD 3.0 PER DIEM
142 1 INTERSTITIAL & ALVEOLAR LUNG DISEAS Med LV PD PD 2.6 PER DIEM
142 2 INTERSTITIAL & ALVEOLAR LUNG DISEAS Med LV PD PD 4.1 PER DIEM
142 3 INTERSTITIAL & ALVEOLAR LUNG DISEAS Med LV PD PD 4.7 PER DIEM
142 4 INTERSTITIAL & ALVEOLAR LUNG DISEAS Med LV PD PD 7.0 PER DIEM
143 1 OTH RESP DX EXC SIGN/SYM/MINOR Med 0.4688 17,726.58 590.97 2.1 APR-DRG
143 2 OTH RESP DX EXC SIGN/SYM/MINOR Med 0.5488 17,726.58 600.93 2.9 APR-DRG
143 3 OTH RESP DX EXC SIGN/SYM/MINOR Med LV PD PD 4.0 PER DIEM
143 4 OTH RESP DX EXC SIGN/SYM/MINOR Med LV PD PD 5.0 PER DIEM
144 1 RESP SIGNS/SYMPTOMS/MINOR DX Med LV PD PD 1.0 PER DIEM
144 2 RESP SIGNS/SYMPTOMS/MINOR DX Med LV PD PD 1.0 PER DIEM
144 3 RESP SIGNS/SYMPTOMS/MINOR DX Med LV PD PD 1.6 PER DIEM
144 4 RESP SIGNS/SYMPTOMS/MINOR DX Med LV PD PD 1.6 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 13
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
160 1 MAJ CARDIOTHOR REPR HEART ANOM Surg LV PD PD 10.0 PER DIEM
160 2 MAJ CARDIOTHOR REPR HEART ANOM Surg LV PD PD 10.0 PER DIEM
160 3 MAJ CARDIOTHOR REPR HEART ANOM Surg LV PD PD 10.0 PER DIEM
160 4 MAJ CARDIOTHOR REPR HEART ANOM Surg LV PD PD 10.0 PER DIEM
161 1 CARD DEFIB/HEART ASST IMPLANT Surg LV PD PD 4.0 PER DIEM
161 2 CARD DEFIB/HEART ASST IMPLANT Surg LV PD PD 7.0 PER DIEM
161 3 CARD DEFIB/HEART ASST IMPLANT Surg LV PD PD 7.0 PER DIEM
161 4 CARD DEFIB/HEART ASST IMPLANT Surg LV PD PD 22.0 PER DIEM
162 1 CARDIAC VALVE PROC W/CATH Surg LV PD PD 11.0 PER DIEM
162 2 CARDIAC VALVE PROC W/CATH Surg LV PD PD 11.0 PER DIEM
162 3 CARDIAC VALVE PROC W/CATH Surg LV PD PD 16.2 PER DIEM
162 4 CARDIAC VALVE PROC W/CATH Surg LV PD PD 16.2 PER DIEM
163 1 CARDIAC VALVE PROC WO CATH Surg LV PD PD 7.5 PER DIEM
163 2 CARDIAC VALVE PROC WO CATH Surg LV PD PD 7.5 PER DIEM
163 3 CARDIAC VALVE PROC WO CATH Surg LV PD PD 7.5 PER DIEM
163 4 CARDIAC VALVE PROC WO CATH Surg LV PD PD 7.5 PER DIEM
165 1 CORONARY BYPASS W CATH/PERCUT Surg LV PD PD 6.0 PER DIEM
165 2 CORONARY BYPASS W CATH/PERCUT Surg LV PD PD 6.0 PER DIEM
165 3 CORONARY BYPASS W CATH/PERCUT Surg LV PD PD 10.0 PER DIEM
165 4 CORONARY BYPASS W CATH/PERCUT Surg LV PD PD 10.0 PER DIEM
166 1 CORONARY BYPASS WO CATH/PERCUT Surg LV PD PD 11.0 PER DIEM
166 2 CORONARY BYPASS WO CATH/PERCUT Surg LV PD PD 11.0 PER DIEM
166 3 CORONARY BYPASS WO CATH/PERCUT Surg LV PD PD 11.0 PER DIEM
166 4 CORONARY BYPASS WO CATH/PERCUT Surg LV PD PD 11.0 PER DIEM
167 1 OTHER CARDIOTHORACIC PROC Surg LV PD PD 3.0 PER DIEM
167 2 OTHER CARDIOTHORACIC PROC Surg LV PD PD 4.7 PER DIEM
167 3 OTHER CARDIOTHORACIC PROC Surg LV PD PD 7.0 PER DIEM
167 4 OTHER CARDIOTHORACIC PROC Surg LV PD PD 15.0 PER DIEM
169 1 MAJ THORAC&ABDOM VASCULAR PROC Surg LV PD PD 4.0 PER DIEM
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Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
169 2 MAJ THORAC&ABDOM VASCULAR PROC Surg LV PD PD 4.0 PER DIEM
169 3 MAJ THORAC&ABDOM VASCULAR PROC Surg LV PD PD 6.5 PER DIEM
169 4 MAJ THORAC&ABDOM VASCULAR PROC Surg LV PD PD 6.5 PER DIEM
170 1 PERM CARD PACEMAK W AMI/HF/SHK Surg LV PD PD 5.0 PER DIEM
170 2 PERM CARD PACEMAK W AMI/HF/SHK Surg LV PD PD 5.0 PER DIEM
170 3 PERM CARD PACEMAK W AMI/HF/SHK Surg LV PD PD 5.0 PER DIEM
170 4 PERM CARD PACEMAK W AMI/HF/SHK Surg LV PD PD 5.0 PER DIEM
171 1 PERM CARD PACEMK WO AMI/HF/SHK Surg LV PD PD 6.0 PER DIEM
171 2 PERM CARD PACEMK WO AMI/HF/SHK Surg LV PD PD 6.0 PER DIEM
171 3 PERM CARD PACEMK WO AMI/HF/SHK Surg LV PD PD 6.0 PER DIEM
171 4 PERM CARD PACEMK WO AMI/HF/SHK Surg LV PD PD 6.0 PER DIEM
173 1 OTHER VASCULAR PROCEDURES Surg 1.0784 19,996.24 1,196.77 2.1 APR-DRG
173 2 OTHER VASCULAR PROCEDURES Surg 1.0784 19,996.24 1,196.77 2.1 APR-DRG
173 3 OTHER VASCULAR PROCEDURES Surg 2.7763 41,202.06 2,130.96 3.7 APR-DRG
173 4 OTHER VASCULAR PROCEDURES Surg LV PD PD 6.0 PER DIEM
174 1 PERCUT CARDIOVASC PROC W/AMI Surg LV PD PD 3.0 PER DIEM
174 2 PERCUT CARDIOVASC PROC W/AMI Surg LV PD PD 3.0 PER DIEM
174 3 PERCUT CARDIOVASC PROC W/AMI Surg LV PD PD 3.0 PER DIEM
174 4 PERCUT CARDIOVASC PROC W/AMI Surg LV PD PD 15.0 PER DIEM
175 1 PERCUT CARDIOVASC WO AMI Surg LV PD PD 1.5 PER DIEM
175 2 PERCUT CARDIOVASC WO AMI Surg LV PD PD 1.8 PER DIEM
175 3 PERCUT CARDIOVASC WO AMI Surg LV PD PD 2.0 PER DIEM
175 4 PERCUT CARDIOVASC WO AMI Surg LV PD PD 2.0 PER DIEM
176 1 CARD PACEMAK & DEFIB REPL Surg LV PD PD 2.8 PER DIEM
176 2 CARD PACEMAK & DEFIB REPL Surg LV PD PD 2.8 PER DIEM
176 3 CARD PACEMAK & DEFIB REPL Surg LV PD PD 5.0 PER DIEM
176 4 CARD PACEMAK & DEFIB REPL Surg LV PD PD 5.0 PER DIEM
177 1 CARD PACEMAK & DEFIB REVIS Surg LV PD PD 3.7 PER DIEM
177 2 CARD PACEMAK & DEFIB REVIS Surg LV PD PD 3.7 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 15
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
177 3 CARD PACEMAK & DEFIB REVIS Surg LV PD PD 3.7 PER DIEM
177 4 CARD PACEMAK & DEFIB REVIS Surg LV PD PD 3.7 PER DIEM
180 1 OTHER CIRCULATORY SYSTEM PROC Surg LV PD PD 7.5 PER DIEM
180 2 OTHER CIRCULATORY SYSTEM PROC Surg LV PD PD 7.5 PER DIEM
180 3 OTHER CIRCULATORY SYSTEM PROC Surg LV PD PD 12.9 PER DIEM
180 4 OTHER CIRCULATORY SYSTEM PROC Surg LV PD PD 12.9 PER DIEM
190 1 ACUTE MYOCARDIAL INFARCT Med LV PD PD 5.0 PER DIEM
190 2 ACUTE MYOCARDIAL INFARCT Med LV PD PD 5.0 PER DIEM
190 3 ACUTE MYOCARDIAL INFARCT Med LV PD PD 5.0 PER DIEM
190 4 ACUTE MYOCARDIAL INFARCT Med LV PD PD 5.0 PER DIEM
191 1 CARD CATHET EXC ISCHEMIA Med LV PD PD 5.0 PER DIEM
191 2 CARD CATHET EXC ISCHEMIA Med LV PD PD 5.0 PER DIEM
191 3 CARD CATHET EXC ISCHEMIA Med LV PD PD 5.0 PER DIEM
191 4 CARD CATHET EXC ISCHEMIA Med LV PD PD 5.0 PER DIEM
192 1 CARD CATHET W/ISCHEMIA Med LV PD PD 2.0 PER DIEM
192 2 CARD CATHET W/ISCHEMIA Med LV PD PD 2.0 PER DIEM
192 3 CARD CATHET W/ISCHEMIA Med LV PD PD 2.0 PER DIEM
192 4 CARD CATHET W/ISCHEMIA Med LV PD PD 2.0 PER DIEM
193 1 ACUTE & SUBACUTE ENDOCARDITIS Med LV PD PD 12.9 PER DIEM
193 2 ACUTE & SUBACUTE ENDOCARDITIS Med LV PD PD 12.9 PER DIEM
193 3 ACUTE & SUBACUTE ENDOCARDITIS Med LV PD PD 12.9 PER DIEM
193 4 ACUTE & SUBACUTE ENDOCARDITIS Med LV PD PD 12.9 PER DIEM
194 1 HEART FAILURE Med LV PD PD 2.0 PER DIEM
194 2 HEART FAILURE Med LV PD PD 2.0 PER DIEM
194 3 HEART FAILURE Med LV PD PD 2.0 PER DIEM
194 4 HEART FAILURE Med LV PD PD 2.0 PER DIEM
196 1 CARDIAC ARREST Med LV PD PD 2.0 PER DIEM
196 2 CARDIAC ARREST Med LV PD PD 2.0 PER DIEM
196 3 CARDIAC ARREST Med LV PD PD 2.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 16
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
196 4 CARDIAC ARREST Med LV PD PD 2.0 PER DIEM
197 1 PERIPHERAL & OTH VASC DIS Med 0.4271 17,726.58 590.97 3.4 APR-DRG
197 2 PERIPHERAL & OTH VASC DIS Med 0.5304 17,726.58 590.97 3.5 APR-DRG
197 3 PERIPHERAL & OTH VASC DIS Med 0.6873 17,726.58 967.80 3.7 APR-DRG
197 4 PERIPHERAL & OTH VASC DIS Med LV PD PD 3.9 PER DIEM
198 1 ANGINA PECT & CORONARY ATH Med LV PD PD 1.7 PER DIEM
198 2 ANGINA PECT & CORONARY ATH Med LV PD PD 1.7 PER DIEM
198 3 ANGINA PECT & CORONARY ATH Med LV PD PD 1.7 PER DIEM
198 4 ANGINA PECT & CORONARY ATH Med LV PD PD 1.7 PER DIEM
199 1 HYPERTENSION Med LV PD PD 5.0 PER DIEM
199 2 HYPERTENSION Med LV PD PD 5.0 PER DIEM
199 3 HYPERTENSION Med LV PD PD 5.0 PER DIEM
199 4 HYPERTENSION Med LV PD PD 5.0 PER DIEM
200 1 CARD STRUCT & VALVE DIS Med LV PD PD 3.8 PER DIEM
200 2 CARD STRUCT & VALVE DIS Med LV PD PD 5.6 PER DIEM
200 3 CARD STRUCT & VALVE DIS Med LV PD PD 5.6 PER DIEM
200 4 CARD STRUCT & VALVE DIS Med LV PD PD 8.0 PER DIEM
201 1 CARD ARRHYTHMIA & CONDUCTN DIS Med LV PD PD 2.5 PER DIEM
201 2 CARD ARRHYTHMIA & CONDUCTN DIS Med LV PD PD 2.5 PER DIEM
201 3 CARD ARRHYTHMIA & CONDUCTN DIS Med 0.4660 17,726.58 590.97 3.0 APR-DRG
201 4 CARD ARRHYTHMIA & CONDUCTN DIS Med 0.4660 17,726.58 590.97 3.0 APR-DRG
203 1 CHEST PAIN Med 0.4094 17,726.58 590.97 1.2 APR-DRG
203 2 CHEST PAIN Med 0.4094 17,726.58 590.97 1.2 APR-DRG
203 3 CHEST PAIN Med 0.4094 17,726.58 590.97 1.2 APR-DRG
203 4 CHEST PAIN Med 0.4094 17,726.58 590.97 1.2 APR-DRG
204 1 SYNCOPE & COLLAPSE Med LV PD PD 1.6 PER DIEM
204 2 SYNCOPE & COLLAPSE Med LV PD PD 1.6 PER DIEM
204 3 SYNCOPE & COLLAPSE Med 0.4697 17,726.58 590.97 2.2 APR-DRG
204 4 SYNCOPE & COLLAPSE Med 0.4697 17,726.58 590.97 2.2 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 17
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
205 1 CARDIOMYOPATHY Med LV PD PD 4.0 PER DIEM
205 2 CARDIOMYOPATHY Med LV PD PD 4.0 PER DIEM
205 3 CARDIOMYOPATHY Med LV PD PD 4.0 PER DIEM
205 4 CARDIOMYOPATHY Med LV PD PD 4.0 PER DIEM
206 1 COMP CARDIAC/VASC DEV OR PROC Med LV PD PD 3.9 PER DIEM
206 2 COMP CARDIAC/VASC DEV OR PROC Med LV PD PD 3.9 PER DIEM
206 3 COMP CARDIAC/VASC DEV OR PROC Med LV PD PD 3.9 PER DIEM
206 4 COMP CARDIAC/VASC DEV OR PROC Med LV PD PD 3.9 PER DIEM
207 1 OTH CIRCULATORY SYSTEM DX Med LV PD PD 2.0 PER DIEM
207 2 OTH CIRCULATORY SYSTEM DX Med LV PD PD 3.8 PER DIEM
207 3 OTH CIRCULATORY SYSTEM DX Med LV PD PD 5.0 PER DIEM
207 4 OTH CIRCULATORY SYSTEM DX Med LV PD PD 7.0 PER DIEM
220 1 MAJ STOM ESOPH DUOD PROC Surg LV PD PD 2.8 PER DIEM
220 2 MAJ STOM ESOPH DUOD PROC Surg 2.0093 40,965.06 2,647.86 4.7 APR-DRG
220 3 MAJ STOM ESOPH DUOD PROC Surg LV PD PD 8.6 PER DIEM
220 4 MAJ STOM ESOPH DUOD PROC Surg LV PD PD 13.0 PER DIEM
221 1 MAJ SMALL & LARGE BOWEL PROC Surg 1.5186 17,726.58 1,263.41 4.4 APR-DRG
221 2 MAJ SMALL & LARGE BOWEL PROC Surg 1.5186 17,726.58 1,263.41 4.4 APR-DRG
221 3 MAJ SMALL & LARGE BOWEL PROC Surg LV PD PD 13.0 PER DIEM
221 4 MAJ SMALL & LARGE BOWEL PROC Surg LV PD PD 13.0 PER DIEM
222 1 OTH STOM, ESOPH, DUOD PROC Surg LV PD PD 3.0 PER DIEM
222 2 OTH STOM, ESOPH, DUOD PROC Surg LV PD PD 3.0 PER DIEM
222 3 OTH STOM, ESOPH, DUOD PROC Surg LV PD PD 3.0 PER DIEM
222 4 OTH STOM, ESOPH, DUOD PROC Surg LV PD PD 3.0 PER DIEM
223 1 OTH SMALL & LARGE BOWEL PROC Surg LV PD PD 3.8 PER DIEM
223 2 OTH SMALL & LARGE BOWEL PROC Surg LV PD PD 4.5 PER DIEM
223 3 OTH SMALL & LARGE BOWEL PROC Surg LV PD PD 8.0 PER DIEM
223 4 OTH SMALL & LARGE BOWEL PROC Surg LV PD PD 10.7 PER DIEM
224 1 PERITONEAL ADHESIOLYSIS Surg LV PD PD 7.0 PER DIEM
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Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
224 2 PERITONEAL ADHESIOLYSIS Surg LV PD PD 7.0 PER DIEM
224 3 PERITONEAL ADHESIOLYSIS Surg LV PD PD 7.0 PER DIEM
224 4 PERITONEAL ADHESIOLYSIS Surg LV PD PD 7.0 PER DIEM
225 1 APPENDECTOMY Surg LV PD PD 1.7 PER DIEM
225 2 APPENDECTOMY Surg LV PD PD 2.5 PER DIEM
225 3 APPENDECTOMY Surg LV PD PD 5.0 PER DIEM
225 4 APPENDECTOMY Surg LV PD PD 7.0 PER DIEM
226 1 ANAL PROCEDURES Surg LV PD PD 3.5 PER DIEM
226 2 ANAL PROCEDURES Surg LV PD PD 4.0 PER DIEM
226 3 ANAL PROCEDURES Surg LV PD PD 5.0 PER DIEM
226 4 ANAL PROCEDURES Surg LV PD PD 6.7 PER DIEM
227 1 HERNIA PROC EXC INGUIN/FEM/UMB Surg 0.6714 17,726.58 603.39 2.2 APR-DRG
227 2 HERNIA PROC EXC INGUIN/FEM/UMB Surg 0.7893 17,726.58 778.79 3.1 APR-DRG
227 3 HERNIA PROC EXC INGUIN/FEM/UMB Surg LV PD PD 4.0 PER DIEM
227 4 HERNIA PROC EXC INGUIN/FEM/UMB Surg LV PD PD 7.9 PER DIEM
228 1 ING FEM & UMBIL HERNIA PROC Surg 0.5651 17,726.58 590.97 1.6 APR-DRG
228 2 ING FEM & UMBIL HERNIA PROC Surg 0.5651 17,726.58 590.97 1.6 APR-DRG
228 3 ING FEM & UMBIL HERNIA PROC Surg LV PD PD 4.0 PER DIEM
228 4 ING FEM & UMBIL HERNIA PROC Surg LV PD PD 4.0 PER DIEM
229 1 OTH DIGEST SYS & ABDOM PROC Surg LV PD PD 3.9 PER DIEM
229 2 OTH DIGEST SYS & ABDOM PROC Surg 1.3149 30,130.79 1,622.68 5.5 APR-DRG
229 3 OTH DIGEST SYS & ABDOM PROC Surg LV PD PD 5.5 PER DIEM
229 4 OTH DIGEST SYS & ABDOM PROC Surg LV PD PD 6.7 PER DIEM
240 1 DIGESTIVE MALIGNANCY Med LV PD PD 5.0 PER DIEM
240 2 DIGESTIVE MALIGNANCY Med LV PD PD 5.0 PER DIEM
240 3 DIGESTIVE MALIGNANCY Med LV PD PD 5.9 PER DIEM
240 4 DIGESTIVE MALIGNANCY Med LV PD PD 5.9 PER DIEM
241 1 PEPTIC ULCER & GASTRITIS Med 0.6410 17,726.58 711.37 4.0 APR-DRG
241 2 PEPTIC ULCER & GASTRITIS Med LV PD PD 4.0 PER DIEM
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Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
241 3 PEPTIC ULCER & GASTRITIS Med 0.9718 17,726.58 808.47 5.8 APR-DRG
241 4 PEPTIC ULCER & GASTRITIS Med LV PD PD 5.8 PER DIEM
242 1 MAJOR ESOPHAGEAL DISORDER Med LV PD PD 4.0 PER DIEM
242 2 MAJOR ESOPHAGEAL DISORDER Med LV PD PD 4.0 PER DIEM
242 3 MAJOR ESOPHAGEAL DISORDER Med LV PD PD 4.0 PER DIEM
242 4 MAJOR ESOPHAGEAL DISORDER Med LV PD PD 4.0 PER DIEM
243 1 OTHER ESOPHAGEAL DISORDER Med LV PD PD 3.0 PER DIEM
243 2 OTHER ESOPHAGEAL DISORDER Med LV PD PD 3.0 PER DIEM
243 3 OTHER ESOPHAGEAL DISORDER Med LV PD PD 3.0 PER DIEM
243 4 OTHER ESOPHAGEAL DISORDER Med LV PD PD 3.0 PER DIEM
244 1 DIVERTICULITIS&DIVERTICULOSIS Med LV PD PD 4.0 PER DIEM
244 2 DIVERTICULITIS&DIVERTICULOSIS Med LV PD PD 4.0 PER DIEM
244 3 DIVERTICULITIS&DIVERTICULOSIS Med LV PD PD 4.0 PER DIEM
244 4 DIVERTICULITIS&DIVERTICULOSIS Med LV PD PD 4.0 PER DIEM
245 1 INFLAMMATORY BOWEL DISEASE Med LV PD PD 4.7 PER DIEM
245 2 INFLAMMATORY BOWEL DISEASE Med LV PD PD 4.7 PER DIEM
245 3 INFLAMMATORY BOWEL DISEASE Med LV PD PD 4.7 PER DIEM
245 4 INFLAMMATORY BOWEL DISEASE Med LV PD PD 4.7 PER DIEM
246 1 GI VASCULAR INSUFFICIENCY Med LV PD PD 5.0 PER DIEM
246 2 GI VASCULAR INSUFFICIENCY Med LV PD PD 5.0 PER DIEM
246 3 GI VASCULAR INSUFFICIENCY Med LV PD PD 5.0 PER DIEM
246 4 GI VASCULAR INSUFFICIENCY Med LV PD PD 5.0 PER DIEM
247 1 INTESTINAL OBSTRUCTION Med LV PD PD 2.7 PER DIEM
247 2 INTESTINAL OBSTRUCTION Med LV PD PD 2.7 PER DIEM
247 3 INTESTINAL OBSTRUCTION Med LV PD PD 3.8 PER DIEM
247 4 INTESTINAL OBSTRUCTION Med LV PD PD 3.8 PER DIEM
248 1 MAJOR GI & PERITONEAL INFECTN Med LV PD PD 6.0 PER DIEM
248 2 MAJOR GI & PERITONEAL INFECTN Med LV PD PD 6.0 PER DIEM
248 3 MAJOR GI & PERITONEAL INFECTN Med LV PD PD 6.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 20
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APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
248 4 MAJOR GI & PERITONEAL INFECTN Med LV PD PD 6.0 PER DIEM
249 1 NON-BACTERIAL GASTROENTERITIS Med LV PD PD 3.0 PER DIEM
249 2 NON-BACTERIAL GASTROENTERITIS Med LV PD PD 3.0 PER DIEM
249 3 NON-BACTERIAL GASTROENTERITIS Med LV PD PD 3.0 PER DIEM
249 4 NON-BACTERIAL GASTROENTERITIS Med LV PD PD 3.0 PER DIEM
251 1 ABDOMINAL PAIN Med 0.4792 17,726.58 590.97 2.5 APR-DRG
251 2 ABDOMINAL PAIN Med 0.5914 17,726.58 590.97 4.0 APR-DRG
251 3 ABDOMINAL PAIN Med LV PD PD 4.0 PER DIEM
251 4 ABDOMINAL PAIN Med LV PD PD 4.0 PER DIEM
252 1 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDUREMed LV PD PD 5.0 PER DIEM
252 2 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDUREMed LV PD PD 5.0 PER DIEM
252 3 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDUREMed LV PD PD 5.0 PER DIEM
252 4 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDUREMed LV PD PD 5.0 PER DIEM
253 1 OTH/UNSPEC GI HEMORRHAGE Med 0.5784 17,726.58 590.97 2.7 APR-DRG
253 2 OTH/UNSPEC GI HEMORRHAGE Med 0.5784 17,726.58 590.97 2.7 APR-DRG
253 3 OTH/UNSPEC GI HEMORRHAGE Med LV PD PD 4.0 PER DIEM
253 4 OTH/UNSPEC GI HEMORRHAGE Med LV PD PD 4.0 PER DIEM
254 1 OTH DIGESTIVE SYSTEM DX Med 0.4437 17,726.58 590.97 2.6 APR-DRG
254 2 OTH DIGESTIVE SYSTEM DX Med 0.5622 17,726.58 590.97 3.6 APR-DRG
254 3 OTH DIGESTIVE SYSTEM DX Med 0.6381 17,726.58 590.97 3.6 APR-DRG
254 4 OTH DIGESTIVE SYSTEM DX Med LV PD PD 4.5 PER DIEM
260 1 MAJ PANCREAS/LIVER/SHUNT PROC Surg LV PD PD 7.0 PER DIEM
260 2 MAJ PANCREAS/LIVER/SHUNT PROC Surg LV PD PD 8.9 PER DIEM
260 3 MAJ PANCREAS/LIVER/SHUNT PROC Surg LV PD PD 8.9 PER DIEM
260 4 MAJ PANCREAS/LIVER/SHUNT PROC Surg LV PD PD 13.6 PER DIEM
261 1 MAJOR BILIARY TRACT PROC Surg LV PD PD 7.0 PER DIEM
261 2 MAJOR BILIARY TRACT PROC Surg LV PD PD 7.0 PER DIEM
261 3 MAJOR BILIARY TRACT PROC Surg LV PD PD 7.8 PER DIEM
261 4 MAJOR BILIARY TRACT PROC Surg LV PD PD 7.8 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 21
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
262 1 CHOLECYSTECTOMY EXC LAP Surg LV PD PD 6.0 PER DIEM
262 2 CHOLECYSTECTOMY EXC LAP Surg LV PD PD 6.0 PER DIEM
262 3 CHOLECYSTECTOMY EXC LAP Surg LV PD PD 10.7 PER DIEM
262 4 CHOLECYSTECTOMY EXC LAP Surg LV PD PD 10.7 PER DIEM
263 1 LAP CHOLECYSTECTOMY Surg LV PD PD 3.0 PER DIEM
263 2 LAP CHOLECYSTECTOMY Surg LV PD PD 3.7 PER DIEM
263 3 LAP CHOLECYSTECTOMY Surg LV PD PD 4.0 PER DIEM
263 4 LAP CHOLECYSTECTOMY Surg LV PD PD 6.0 PER DIEM
264 1 OTH HEPATOB/PANCREAS/ABDM PROC Surg LV PD PD 4.0 PER DIEM
264 2 OTH HEPATOB/PANCREAS/ABDM PROC Surg LV PD PD 7.0 PER DIEM
264 3 OTH HEPATOB/PANCREAS/ABDM PROC Surg LV PD PD 7.0 PER DIEM
264 4 OTH HEPATOB/PANCREAS/ABDM PROC Surg LV PD PD 9.0 PER DIEM
279 1 HEPATIC COMA/OTH MAJ LIV DIS Med LV PD PD 7.0 PER DIEM
279 2 HEPATIC COMA/OTH MAJ LIV DIS Med LV PD PD 7.0 PER DIEM
279 3 HEPATIC COMA/OTH MAJ LIV DIS Med LV PD PD 7.0 PER DIEM
279 4 HEPATIC COMA/OTH MAJ LIV DIS Med LV PD PD 7.0 PER DIEM
280 1 ALCOHOLIC LIVER DISEASE Med LV PD PD 5.0 PER DIEM
280 2 ALCOHOLIC LIVER DISEASE Med LV PD PD 5.0 PER DIEM
280 3 ALCOHOLIC LIVER DISEASE Med LV PD PD 5.0 PER DIEM
280 4 ALCOHOLIC LIVER DISEASE Med LV PD PD 5.0 PER DIEM
281 1 MALIGNCY-HEPATOBIL & PANCREAS Med LV PD PD 4.8 PER DIEM
281 2 MALIGNCY-HEPATOBIL & PANCREAS Med LV PD PD 4.8 PER DIEM
281 3 MALIGNCY-HEPATOBIL & PANCREAS Med LV PD PD 4.8 PER DIEM
281 4 MALIGNCY-HEPATOBIL & PANCREAS Med LV PD PD 4.8 PER DIEM
282 1 PANCREAS DISORD EXC MALIG Med LV PD PD 4.0 PER DIEM
282 2 PANCREAS DISORD EXC MALIG Med LV PD PD 4.0 PER DIEM
282 3 PANCREAS DISORD EXC MALIG Med LV PD PD 9.0 PER DIEM
282 4 PANCREAS DISORD EXC MALIG Med LV PD PD 9.0 PER DIEM
283 1 OTHER DISORDERS OF LIVER Med 0.4587 17,726.58 592.62 2.7 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 22
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
283 2 OTHER DISORDERS OF LIVER Med 0.4587 17,726.58 592.62 2.7 APR-DRG
283 3 OTHER DISORDERS OF LIVER Med 0.7007 17,726.58 590.97 4.0 APR-DRG
283 4 OTHER DISORDERS OF LIVER Med 0.7007 17,726.58 590.97 4.0 APR-DRG
284 1 DIS GALLBLADDER & BILIARY TRCT Med LV PD PD 3.0 PER DIEM
284 2 DIS GALLBLADDER & BILIARY TRCT Med LV PD PD 3.0 PER DIEM
284 3 DIS GALLBLADDER & BILIARY TRCT Med LV PD PD 5.0 PER DIEM
284 4 DIS GALLBLADDER & BILIARY TRCT Med LV PD PD 5.0 PER DIEM
301 1 HIP JOINT REPLACEMENT Surg 1.4517 25,346.22 1,611.07 3.4 APR-DRG
301 2 HIP JOINT REPLACEMENT Surg 1.4517 25,346.22 1,611.07 3.4 APR-DRG
301 3 HIP JOINT REPLACEMENT Surg 1.4848 26,436.83 1,647.74 3.8 APR-DRG
301 4 HIP JOINT REPLACEMENT Surg 1.4848 26,436.83 1,647.74 3.8 APR-DRG
302 1 KNEE JOINT REPLACEMENT Surg 1.2695 19,730.67 1,240.65 3.1 APR-DRG
302 2 KNEE JOINT REPLACEMENT Surg 1.2695 19,730.67 1,240.65 3.1 APR-DRG
302 3 KNEE JOINT REPLACEMENT Surg 1.3226 26,093.55 1,467.76 3.1 APR-DRG
302 4 KNEE JOINT REPLACEMENT Surg 1.3226 19,730.67 1,240.65 3.1 APR-DRG
303 1 DORS/LUMB FUSION FOR CURV BACK Surg LV PD PD 5.8 PER DIEM
303 2 DORS/LUMB FUSION FOR CURV BACK Surg LV PD PD 5.8 PER DIEM
303 3 DORS/LUMB FUSION FOR CURV BACK Surg LV PD PD 5.8 PER DIEM
303 4 DORS/LUMB FUSION FOR CURV BACK Surg LV PD PD 5.8 PER DIEM
304 1 DORS/LUMB FUSION EXC CURV BACK Surg 2.3356 42,303.37 2,592.02 3.2 APR-DRG
304 2 DORS/LUMB FUSION EXC CURV BACK Surg 2.3356 42,303.37 2,592.02 3.2 APR-DRG
304 3 DORS/LUMB FUSION EXC CURV BACK Surg 2.5930 46,991.16 2,877.62 4.1 APR-DRG
304 4 DORS/LUMB FUSION EXC CURV BACK Surg 2.5930 46,991.16 2,877.62 4.1 APR-DRG
305 1 AMPUTATION LOWER LIMB EXC TOE Surg 0.9015 21,338.61 1,546.38 3.8 APR-DRG
305 2 AMPUTATION LOWER LIMB EXC TOE Surg 0.9015 21,338.61 1,546.38 3.8 APR-DRG
305 3 AMPUTATION LOWER LIMB EXC TOE Surg 0.9034 21,338.61 1,546.38 5.4 APR-DRG
305 4 AMPUTATION LOWER LIMB EXC TOE Surg 0.9034 21,338.61 1,546.38 5.4 APR-DRG
308 1 HIP/FEM PROC EXC JT REPL-TRAUM Surg 2.2080 27,033.03 1,433.26 4.4 APR-DRG
308 2 HIP/FEM PROC EXC JT REPL-TRAUM Surg 2.2080 27,033.03 1,433.26 4.4 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 23
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
308 3 HIP/FEM PROC EXC JT REPL-TRAUM Surg 2.2080 27,033.03 1,433.26 4.4 APR-DRG
308 4 HIP/FEM PROC EXC JT REPL-TRAUM Surg 2.2080 27,033.03 1,433.26 4.4 APR-DRG
309 1 HIP/FEM PROC EXC JT RPL-NONTR Surg 0.6855 17,726.58 798.86 2.4 APR-DRG
309 2 HIP/FEM PROC EXC JT RPL-NONTR Surg 0.9199 17,726.58 950.91 3.0 APR-DRG
309 3 HIP/FEM PROC EXC JT RPL-NONTR Surg LV PD PD 3.3 PER DIEM
309 4 HIP/FEM PROC EXC JT RPL-NONTR Surg LV PD PD 3.3 PER DIEM
310 1 INTERVERTEBRAL DISC EXCISION Surg LV PD PD 2.0 PER DIEM
310 2 INTERVERTEBRAL DISC EXCISION Surg LV PD PD 2.0 PER DIEM
310 3 INTERVERTEBRAL DISC EXCISION Surg LV PD PD 2.0 PER DIEM
310 4 INTERVERTEBRAL DISC EXCISION Surg LV PD PD 2.0 PER DIEM
312 1 SKIN GRFT EXC HAND-MSCKL/CONN Surg 0.7797 17,726.58 1,068.11 3.8 APR-DRG
312 2 SKIN GRFT EXC HAND-MSCKL/CONN Surg 0.7797 17,726.58 1,068.11 3.8 APR-DRG
312 3 SKIN GRFT EXC HAND-MSCKL/CONN Surg 1.9056 28,146.36 1,361.88 4.6 APR-DRG
312 4 SKIN GRFT EXC HAND-MSCKL/CONN Surg 1.9056 28,146.36 1,361.88 4.6 APR-DRG
313 1 KNEE & LOWER LEG PROC EXC FOOT Surg 0.7915 17,726.58 878.41 2.0 APR-DRG
313 2 KNEE & LOWER LEG PROC EXC FOOT Surg 0.8272 17,726.58 771.38 2.2 APR-DRG
313 3 KNEE & LOWER LEG PROC EXC FOOT Surg 0.9621 17,726.58 1,003.34 3.1 APR-DRG
313 4 KNEE & LOWER LEG PROC EXC FOOT Surg 1.1997 17,726.58 998.02 4.1 APR-DRG
314 1 FOOT & TOE PROCEDURES Surg 0.7804 17,726.58 822.37 2.1 APR-DRG
314 2 FOOT & TOE PROCEDURES Surg 0.7804 17,726.58 822.37 2.1 APR-DRG
314 3 FOOT & TOE PROCEDURES Surg LV PD PD 3.0 PER DIEM
314 4 FOOT & TOE PROCEDURES Surg LV PD PD 3.0 PER DIEM
315 1 SHOULDER UPPER ARM FOREARM PROC Surg 0.7129 17,726.58 623.67 1.7 APR-DRG
315 2 SHOULDER UPPER ARM FOREARM PROC Surg 0.7759 17,726.58 594.62 1.7 APR-DRG
315 3 SHOULDER UPPER ARM FOREARM PROC Surg 0.7759 17,726.58 594.62 1.7 APR-DRG
315 4 SHOULDER UPPER ARM FOREARM PROC Surg 1.2239 19,980.68 1,358.26 1.8 APR-DRG
316 1 HAND & WRIST PROCEDURES Surg 0.6159 17,726.58 602.59 2.0 APR-DRG
316 2 HAND & WRIST PROCEDURES Surg 0.6883 23,639.29 827.93 2.2 APR-DRG
316 3 HAND & WRIST PROCEDURES Surg 0.7037 17,726.58 743.99 2.8 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 24
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
316 4 HAND & WRIST PROCEDURES Surg 0.7037 17,726.58 743.99 2.8 APR-DRG
317 1 TENDON/MUSCLE/SOFT TISS PROC Surg 0.6790 17,726.58 1,092.38 2.1 APR-DRG
317 2 TENDON/MUSCLE/SOFT TISS PROC Surg 0.6791 17,726.58 628.24 2.2 APR-DRG
317 3 TENDON/MUSCLE/SOFT TISS PROC Surg 0.7394 17,726.58 731.15 3.4 APR-DRG
317 4 TENDON/MUSCLE/SOFT TISS PROC Surg 0.7394 17,726.58 731.15 3.4 APR-DRG
320 1 OTH MUSCULOSKELETAL PROC Surg 0.8478 17,726.58 828.47 2.0 APR-DRG
320 2 OTH MUSCULOSKELETAL PROC Surg 1.9717 26,878.62 1,729.09 3.0 APR-DRG
320 3 OTH MUSCULOSKELETAL PROC Surg 2.0162 34,707.95 2,237.55 3.5 APR-DRG
320 4 OTH MUSCULOSKELETAL PROC Surg LV PD PD 3.6 PER DIEM
321 1 CERV SPINAL FUS/OTH BACK&NK PR Surg 1.0274 17,726.58 1,140.19 1.3 APR-DRG
321 2 CERV SPINAL FUS/OTH BACK&NK PR Surg 1.2819 22,361.51 1,422.54 1.7 APR-DRG
321 3 CERV SPINAL FUS/OTH BACK&NK PR Surg 3.0943 54,411.91 3,433.94 3.7 APR-DRG
321 4 CERV SPINAL FUS/OTH BACK&NK PR Surg 4.6704 90,827.53 5,183.07 6.5 APR-DRG
340 1 FRACTURE OF FEMUR Med LV PD PD 3.0 PER DIEM
340 2 FRACTURE OF FEMUR Med LV PD PD 3.0 PER DIEM
340 3 FRACTURE OF FEMUR Med LV PD PD 5.5 PER DIEM
340 4 FRACTURE OF FEMUR Med LV PD PD 5.5 PER DIEM
341 1 FX PELVIS/HIP DISLOCATION Med 0.5010 17,726.58 607.09 3.3 APR-DRG
341 2 FX PELVIS/HIP DISLOCATION Med 0.5010 17,726.58 607.09 3.3 APR-DRG
341 3 FX PELVIS/HIP DISLOCATION Med 0.5010 17,726.58 607.09 3.3 APR-DRG
341 4 FX PELVIS/HIP DISLOCATION Med 0.5010 17,726.58 607.09 3.3 APR-DRG
342 1 FX&DISLOCAT EXC FEM/PELV/BACK Med 0.4493 17,726.58 590.97 2.0 APR-DRG
342 2 FX&DISLOCAT EXC FEM/PELV/BACK Med LV PD PD 2.0 PER DIEM
342 3 FX&DISLOCAT EXC FEM/PELV/BACK Med 0.5269 17,726.58 590.97 2.5 APR-DRG
342 4 FX&DISLOCAT EXC FEM/PELV/BACK Med LV PD PD 3.2 PER DIEM
343 1 MUSCULOSKEL MALIGN & PATHOL FX Surg 0.6309 17,726.58 700.11 1.5 APR-DRG
343 2 MUSCULOSKEL MALIGN & PATHOL FX Surg 0.7686 17,726.58 829.78 2.1 APR-DRG
343 3 MUSCULOSKEL MALIGN & PATHOL FX Surg 0.7700 17,726.58 854.51 2.2 APR-DRG
343 4 MUSCULOSKEL MALIGN & PATHOL FX Surg 2.6603 26,624.23 1,482.31 4.1 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 25
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
344 1 BONE/JOINT/OTH MUSCSKEL INFECT Med 0.7210 17,726.58 925.05 4.4 APR-DRG
344 2 BONE/JOINT/OTH MUSCSKEL INFECT Med 0.8244 17,726.58 685.84 4.4 APR-DRG
344 3 BONE/JOINT/OTH MUSCSKEL INFECT Med 0.8244 17,726.58 685.84 5.6 APR-DRG
344 4 BONE/JOINT/OTH MUSCSKEL INFECT Med 0.8244 17,726.58 685.84 5.6 APR-DRG
346 1 CONNECTIVE TISSUE DISORDER Med 0.4193 17,726.58 590.97 3.0 APR-DRG
346 2 CONNECTIVE TISSUE DISORDER Med 0.4654 17,726.58 590.97 3.3 APR-DRG
346 3 CONNECTIVE TISSUE DISORDER Med 0.4687 17,726.58 590.97 3.5 APR-DRG
346 4 CONNECTIVE TISSUE DISORDER Med LV PD PD 5.0 PER DIEM
347 1 BACK & NECK DIS FRACT & INJ Med 0.5157 17,726.58 590.97 2.9 APR-DRG
347 2 BACK & NECK DIS FRACT & INJ Med 0.5157 17,726.58 590.97 2.9 APR-DRG
347 3 BACK & NECK DIS FRACT & INJ Med 0.5157 17,726.58 590.97 2.9 APR-DRG
347 4 BACK & NECK DIS FRACT & INJ Med 0.5157 17,726.58 590.97 2.9 APR-DRG
349 1 MALF/REACT/COMP ORTH DEV/PROC Med 0.4480 17,726.58 621.05 3.2 APR-DRG
349 2 MALF/REACT/COMP ORTH DEV/PROC Med 0.4480 17,726.58 621.05 3.2 APR-DRG
349 3 MALF/REACT/COMP ORTH DEV/PROC Med 0.4480 17,726.58 621.05 3.2 APR-DRG
349 4 MALF/REACT/COMP ORTH DEV/PROC Med 0.4480 17,726.58 621.05 3.2 APR-DRG
351 1 OTH MUSCULOSKL & CONN TISS DX Med 0.4067 17,726.58 590.97 2.3 APR-DRG
351 2 OTH MUSCULOSKL & CONN TISS DX Med 0.4078 17,726.58 590.97 3.0 APR-DRG
351 3 OTH MUSCULOSKL & CONN TISS DX Med 0.4904 17,726.58 618.67 3.2 APR-DRG
351 4 OTH MUSCULOSKL & CONN TISS DX Med LV PD PD 3.8 PER DIEM
361 1 SKIN GRAFT-SKIN & SUBCU DX Surg 0.6352 17,726.58 798.79 2.3 APR-DRG
361 2 SKIN GRAFT-SKIN & SUBCU DX Surg 0.6665 17,726.58 762.78 2.7 APR-DRG
361 3 SKIN GRAFT-SKIN & SUBCU DX Surg 0.7453 17,726.58 761.92 2.7 APR-DRG
361 4 SKIN GRAFT-SKIN & SUBCU DX Surg 0.7528 17,726.58 842.42 3.5 APR-DRG
362 1 MASTECTOMY PROCEDURES Surg LV PD PD 1.0 PER DIEM
362 2 MASTECTOMY PROCEDURES Surg LV PD PD 1.8 PER DIEM
362 3 MASTECTOMY PROCEDURES Surg LV PD PD 1.9 PER DIEM
362 4 MASTECTOMY PROCEDURES Surg LV PD PD 2.0 PER DIEM
363 1 BREAST PROC EXC MASTECTOMY Surg 1.0172 25,868.83 1,490.18 5.1 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 26
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
363 2 BREAST PROC EXC MASTECTOMY Surg LV PD PD 2.0 PER DIEM
363 3 BREAST PROC EXC MASTECTOMY Surg LV PD PD 2.0 PER DIEM
363 4 BREAST PROC EXC MASTECTOMY Surg LV PD PD 3.0 PER DIEM
364 1 OTHER SKIN & SUBCUT PROC Surg 0.5924 17,726.58 607.35 2.3 APR-DRG
364 2 OTHER SKIN & SUBCUT PROC Surg 1.0510 17,726.58 874.42 4.1 APR-DRG
364 3 OTHER SKIN & SUBCUT PROC Surg 1.3624 17,726.58 1,133.44 4.3 APR-DRG
364 4 OTHER SKIN & SUBCUT PROC Surg 2.0742 20,404.26 1,273.55 4.5 APR-DRG
380 1 SKIN ULCERS Med 0.5644 17,726.58 676.09 4.5 APR-DRG
380 2 SKIN ULCERS Med 0.5644 17,726.58 676.09 4.5 APR-DRG
380 3 SKIN ULCERS Med 0.5644 17,726.58 676.09 4.5 APR-DRG
380 4 SKIN ULCERS Med 0.5644 17,726.58 676.09 4.5 APR-DRG
381 1 MAJOR SKIN DISORDERS Med LV PD PD 2.8 PER DIEM
381 2 MAJOR SKIN DISORDERS Med 0.6540 17,726.58 711.57 5.1 APR-DRG
381 3 MAJOR SKIN DISORDERS Med LV PD PD 6.0 PER DIEM
381 4 MAJOR SKIN DISORDERS Med LV PD PD 14.9 PER DIEM
382 1 MALIGNANT BREAST DISORDERS Med LV PD PD 3.0 PER DIEM
382 2 MALIGNANT BREAST DISORDERS Med LV PD PD 3.0 PER DIEM
382 3 MALIGNANT BREAST DISORDERS Med LV PD PD 4.9 PER DIEM
382 4 MALIGNANT BREAST DISORDERS Med LV PD PD 4.9 PER DIEM
383 1 CELLULITIS & OTH BACT SKIN INF Med 0.3832 17,726.58 590.97 2.9 APR-DRG
383 2 CELLULITIS & OTH BACT SKIN INF Med 0.4988 17,726.58 590.97 3.5 APR-DRG
383 3 CELLULITIS & OTH BACT SKIN INF Med LV PD PD 3.5 PER DIEM
383 4 CELLULITIS & OTH BACT SKIN INF Med LV PD PD 3.5 PER DIEM
384 1 CONTUSION/OPEN WND SKIN/OTH TR Med 0.4629 17,726.58 590.97 1.5 APR-DRG
384 2 CONTUSION/OPEN WND SKIN/OTH TR Med 0.5570 17,726.58 590.97 1.8 APR-DRG
384 3 CONTUSION/OPEN WND SKIN/OTH TR Med LV PD PD 3.4 PER DIEM
384 4 CONTUSION/OPEN WND SKIN/OTH TR Med LV PD PD 3.4 PER DIEM
385 1 OTH SKIN/SUBCUT/BREAST DIS Med LV PD PD 2.6 PER DIEM
385 2 OTH SKIN/SUBCUT/BREAST DIS Med LV PD PD 3.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 27
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
385 3 OTH SKIN/SUBCUT/BREAST DIS Med LV PD PD 3.0 PER DIEM
385 4 OTH SKIN/SUBCUT/BREAST DIS Med LV PD PD 4.0 PER DIEM
401 1 PITUITARY & ADRENAL PROC Surg LV PD PD 5.0 PER DIEM
401 2 PITUITARY & ADRENAL PROC Surg LV PD PD 5.0 PER DIEM
401 3 PITUITARY & ADRENAL PROC Surg LV PD PD 5.0 PER DIEM
401 4 PITUITARY & ADRENAL PROC Surg LV PD PD 5.0 PER DIEM
403 1 PROCEDURES FOR OBESITY Surg LV PD PD 4.0 PER DIEM
403 2 PROCEDURES FOR OBESITY Surg LV PD PD 4.0 PER DIEM
403 3 PROCEDURES FOR OBESITY Surg LV PD PD 4.0 PER DIEM
403 4 PROCEDURES FOR OBESITY Surg LV PD PD 4.0 PER DIEM
404 1 THYROID/PARATHYRD/THYROGL PROC Surg LV PD PD 1.5 PER DIEM
404 2 THYROID/PARATHYRD/THYROGL PROC Surg LV PD PD 1.5 PER DIEM
404 3 THYROID/PARATHYRD/THYROGL PROC Surg LV PD PD 1.6 PER DIEM
404 4 THYROID/PARATHYRD/THYROGL PROC Surg LV PD PD 1.6 PER DIEM
405 1 OTH PROC-ENDOCR/NUTRIT/MET DX Surg LV PD PD 4.0 PER DIEM
405 2 OTH PROC-ENDOCR/NUTRIT/MET DX Surg LV PD PD 6.9 PER DIEM
405 3 OTH PROC-ENDOCR/NUTRIT/MET DX Surg LV PD PD 8.0 PER DIEM
405 4 OTH PROC-ENDOCR/NUTRIT/MET DX Surg LV PD PD 12.0 PER DIEM
420 1 DIABETES Med LV PD PD 2.6 PER DIEM
420 2 DIABETES Med LV PD PD 2.6 PER DIEM
420 3 DIABETES Med LV PD PD 2.8 PER DIEM
420 4 DIABETES Med LV PD PD 2.8 PER DIEM
421 1 MALNUT FAIL THRIVE OTH NUTR DX Med LV PD PD 2.6 PER DIEM
421 2 MALNUT FAIL THRIVE OTH NUTR DX Med LV PD PD 2.6 PER DIEM
421 3 MALNUT FAIL THRIVE OTH NUTR DX Med LV PD PD 2.6 PER DIEM
421 4 MALNUT FAIL THRIVE OTH NUTR DX Med LV PD PD 2.6 PER DIEM
422 1 HYPOVOLEM/RELAT ELECTROLYTE DX Med LV PD PD 3.0 PER DIEM
422 2 HYPOVOLEM/RELAT ELECTROLYTE DX Med LV PD PD 3.0 PER DIEM
422 3 HYPOVOLEM/RELAT ELECTROLYTE DX Med LV PD PD 3.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 28
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
422 4 HYPOVOLEM/RELAT ELECTROLYTE DX Med LV PD PD 3.0 PER DIEM
423 1 INBORN ERRORS METABOLISM Med LV PD PD 6.0 PER DIEM
423 2 INBORN ERRORS METABOLISM Med LV PD PD 6.0 PER DIEM
423 3 INBORN ERRORS METABOLISM Med LV PD PD 6.0 PER DIEM
423 4 INBORN ERRORS METABOLISM Med LV PD PD 6.0 PER DIEM
424 1 OTH ENDOCRINE DISORDERS Med 0.6272 17,726.58 590.97 3.7 APR-DRG
424 2 OTH ENDOCRINE DISORDERS Med LV PD PD 3.7 PER DIEM
424 3 OTH ENDOCRINE DISORDERS Med LV PD PD 4.0 PER DIEM
424 4 OTH ENDOCRINE DISORDERS Med LV PD PD 4.0 PER DIEM
425 1 ELECTROLYTE DIS EXC HYPOVOL Med LV PD PD 4.0 PER DIEM
425 2 ELECTROLYTE DIS EXC HYPOVOL Med LV PD PD 4.0 PER DIEM
425 3 ELECTROLYTE DIS EXC HYPOVOL Med LV PD PD 4.0 PER DIEM
425 4 ELECTROLYTE DIS EXC HYPOVOL Med LV PD PD 4.0 PER DIEM
440 1 KIDNEY TRANSPLANT Surg LV PD PD 8.0 PER DIEM
440 2 KIDNEY TRANSPLANT Surg LV PD PD 8.0 PER DIEM
440 3 KIDNEY TRANSPLANT Surg LV PD PD 8.0 PER DIEM
440 4 KIDNEY TRANSPLANT Surg LV PD PD 8.0 PER DIEM
441 1 MAJOR BLADDER PROC Surg LV PD PD 9.0 PER DIEM
441 2 MAJOR BLADDER PROC Surg LV PD PD 9.0 PER DIEM
441 3 MAJOR BLADDER PROC Surg LV PD PD 9.0 PER DIEM
441 4 MAJOR BLADDER PROC Surg LV PD PD 9.0 PER DIEM
442 1 KIDNEY/URINARY TRCT PROC-MALIG Surg LV PD PD 5.0 PER DIEM
442 2 KIDNEY/URINARY TRCT PROC-MALIG Surg LV PD PD 5.0 PER DIEM
442 3 KIDNEY/URINARY TRCT PROC-MALIG Surg LV PD PD 5.0 PER DIEM
442 4 KIDNEY/URINARY TRCT PROC-MALIG Surg LV PD PD 5.0 PER DIEM
443 1 KIDNEY/URIN TRCT PROC-NONMALIG Surg LV PD PD 3.0 PER DIEM
443 2 KIDNEY/URIN TRCT PROC-NONMALIG Surg LV PD PD 4.7 PER DIEM
443 3 KIDNEY/URIN TRCT PROC-NONMALIG Surg LV PD PD 5.9 PER DIEM
443 4 KIDNEY/URIN TRCT PROC-NONMALIG Surg LV PD PD 11.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 29
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
444 1 RENAL DIALY ACC DEV PROC ONLY Surg LV PD PD 2.9 PER DIEM
444 2 RENAL DIALY ACC DEV PROC ONLY Surg LV PD PD 2.9 PER DIEM
444 3 RENAL DIALY ACC DEV PROC ONLY Surg LV PD PD 2.9 PER DIEM
444 4 RENAL DIALY ACC DEV PROC ONLY Surg LV PD PD 2.9 PER DIEM
445 1 OTHER BLADDER PROC Surg LV PD PD 1.7 PER DIEM
445 2 OTHER BLADDER PROC Surg LV PD PD 1.7 PER DIEM
445 3 OTHER BLADDER PROC Surg LV PD PD 2.8 PER DIEM
445 4 OTHER BLADDER PROC Surg LV PD PD 2.8 PER DIEM
446 1 URETHRAL & TRANSURETH PROC Surg LV PD PD 1.9 PER DIEM
446 2 URETHRAL & TRANSURETH PROC Surg LV PD PD 2.0 PER DIEM
446 3 URETHRAL & TRANSURETH PROC Surg LV PD PD 2.0 PER DIEM
446 4 URETHRAL & TRANSURETH PROC Surg LV PD PD 3.0 PER DIEM
447 1 OTH KID/URIN TRACT & REL PROC Surg LV PD PD 1.7 PER DIEM
447 2 OTH KID/URIN TRACT & REL PROC Surg LV PD PD 4.0 PER DIEM
447 3 OTH KID/URIN TRACT & REL PROC Surg LV PD PD 4.0 PER DIEM
447 4 OTH KID/URIN TRACT & REL PROC Surg LV PD PD 4.8 PER DIEM
460 1 RENAL FAILURE Med LV PD PD 4.6 PER DIEM
460 2 RENAL FAILURE Med LV PD PD 4.6 PER DIEM
460 3 RENAL FAILURE Med LV PD PD 8.0 PER DIEM
460 4 RENAL FAILURE Med LV PD PD 8.0 PER DIEM
461 1 KIDNEY/URINARY TRACT MALIG Med LV PD PD 2.7 PER DIEM
461 2 KIDNEY/URINARY TRACT MALIG Med LV PD PD 2.7 PER DIEM
461 3 KIDNEY/URINARY TRACT MALIG Med 0.4964 17,726.58 590.97 2.8 APR-DRG
461 4 KIDNEY/URINARY TRACT MALIG Med 0.4964 17,726.58 590.97 4.0 APR-DRG
462 1 NEPHRITIS & NEPHROSIS Med LV PD PD 4.0 PER DIEM
462 2 NEPHRITIS & NEPHROSIS Med LV PD PD 4.0 PER DIEM
462 3 NEPHRITIS & NEPHROSIS Med LV PD PD 4.0 PER DIEM
462 4 NEPHRITIS & NEPHROSIS Med LV PD PD 4.0 PER DIEM
463 1 KIDNEY/URIN TRACT INFECT Med LV PD PD 4.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 30
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
463 2 KIDNEY/URIN TRACT INFECT Med LV PD PD 4.0 PER DIEM
463 3 KIDNEY/URIN TRACT INFECT Med LV PD PD 4.0 PER DIEM
463 4 KIDNEY/URIN TRACT INFECT Med LV PD PD 4.0 PER DIEM
465 1 URIN STONES&ACQ UP URIN OBSTR Med LV PD PD 2.0 PER DIEM
465 2 URIN STONES&ACQ UP URIN OBSTR Med LV PD PD 2.0 PER DIEM
465 3 URIN STONES&ACQ UP URIN OBSTR Med LV PD PD 2.0 PER DIEM
465 4 URIN STONES&ACQ UP URIN OBSTR Med LV PD PD 2.0 PER DIEM
466 1 MALF/REAC/COMP GU DEVICE/PROC Surg 0.7380 17,726.58 818.94 2.2 APR-DRG
466 2 MALF/REAC/COMP GU DEVICE/PROC Surg 0.7380 17,726.58 818.94 2.2 APR-DRG
466 3 MALF/REAC/COMP GU DEVICE/PROC Surg 0.8532 17,726.58 946.86 3.1 APR-DRG
466 4 MALF/REAC/COMP GU DEVICE/PROC Surg 0.8532 17,726.58 946.86 3.1 APR-DRG
468 1 OTH KIDNEY/URINARY TRACT DX Med 0.6335 17,726.58 590.97 1.7 APR-DRG
468 2 OTH KIDNEY/URINARY TRACT DX Med 0.6618 17,726.58 590.97 1.8 APR-DRG
468 3 OTH KIDNEY/URINARY TRACT DX Med LV PD PD 2.6 PER DIEM
468 4 OTH KIDNEY/URINARY TRACT DX Med LV PD PD 5.0 PER DIEM
480 1 MAJOR MALE PELVIC PROC Surg LV PD PD 2.5 PER DIEM
480 2 MAJOR MALE PELVIC PROC Surg LV PD PD 2.5 PER DIEM
480 3 MAJOR MALE PELVIC PROC Surg LV PD PD 4.0 PER DIEM
480 4 MAJOR MALE PELVIC PROC Surg LV PD PD 4.0 PER DIEM
481 1 PENIS PROCEDURES Surg LV PD PD 0.0 PER DIEM
481 2 PENIS PROCEDURES Surg LV PD PD 0.0 PER DIEM
481 3 PENIS PROCEDURES Surg LV PD PD 3.8 PER DIEM
481 4 PENIS PROCEDURES Surg LV PD PD 3.8 PER DIEM
482 1 TRANSURETHRAL PROSTATECTOMY Surg LV PD PD 1.6 PER DIEM
482 2 TRANSURETHRAL PROSTATECTOMY Surg LV PD PD 1.6 PER DIEM
482 3 TRANSURETHRAL PROSTATECTOMY Surg LV PD PD 1.7 APR-DRG
482 4 TRANSURETHRAL PROSTATECTOMY Surg LV PD PD 1.7 APR-DRG
483 1 TESTES & SCROTAL PROC Surg LV PD PD 2.0 PER DIEM
483 2 TESTES & SCROTAL PROC Surg LV PD PD 2.5 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 31
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
483 3 TESTES & SCROTAL PROC Surg 0.5969 17,726.58 590.97 2.5 APR-DRG
483 4 TESTES & SCROTAL PROC Surg 0.5969 17,726.58 590.97 4.0 APR-DRG
484 1 OTH MALE REPROD SYST/REL PROC Surg LV PD PD 4.0 PER DIEM
484 2 OTH MALE REPROD SYST/REL PROC Surg LV PD PD 4.0 PER DIEM
484 3 OTH MALE REPROD SYST/REL PROC Surg LV PD PD 4.0 PER DIEM
484 4 OTH MALE REPROD SYST/REL PROC Surg LV PD PD 4.0 PER DIEM
500 1 MALIGNANCY MALE REPROD SYS Med LV PD PD 3.8 PER DIEM
500 2 MALIGNANCY MALE REPROD SYS Med LV PD PD 3.8 PER DIEM
500 3 MALIGNANCY MALE REPROD SYS Med LV PD PD 4.0 PER DIEM
500 4 MALIGNANCY MALE REPROD SYS Med LV PD PD 4.0 PER DIEM
501 1 MALE REPROD SYS DX EXC MALIG Med LV PD PD 2.0 PER DIEM
501 2 MALE REPROD SYS DX EXC MALIG Med LV PD PD 3.0 PER DIEM
501 3 MALE REPROD SYS DX EXC MALIG Med LV PD PD 4.0 PER DIEM
501 4 MALE REPROD SYS DX EXC MALIG Med LV PD PD 5.0 PER DIEM
510 1 PELVIC EVISC/RAD HYSTERECTOMY Surg LV PD PD 4.5 PER DIEM
510 2 PELVIC EVISC/RAD HYSTERECTOMY Surg LV PD PD 4.5 PER DIEM
510 3 PELVIC EVISC/RAD HYSTERECTOMY Surg LV PD PD 4.5 PER DIEM
510 4 PELVIC EVISC/RAD HYSTERECTOMY Surg LV PD PD 4.5 PER DIEM
511 1 UTER/ADNEX PROC-OVAR/AD MAL Surg LV PD PD 2.9 PER DIEM
511 2 UTER/ADNEX PROC-OVAR/AD MAL Surg LV PD PD 3.0 PER DIEM
511 3 UTER/ADNEX PROC-OVAR/AD MAL Surg LV PD PD 4.0 PER DIEM
511 4 UTER/ADNEX PROC-OVAR/AD MAL Surg LV PD PD 7.0 PER DIEM
512 1 UTER/ADNEX PROC-NON-OV/AD MAL Surg LV PD PD 3.0 PER DIEM
512 2 UTER/ADNEX PROC-NON-OV/AD MAL Surg LV PD PD 3.0 PER DIEM
512 3 UTER/ADNEX PROC-NON-OV/AD MAL Surg LV PD PD 4.0 PER DIEM
512 4 UTER/ADNEX PROC-NON-OV/AD MAL Surg LV PD PD 4.0 PER DIEM
513 1 UTER/ADNX PROC-NONMAL EXC LEIO Surg LV PD PD 2.0 PER DIEM
513 2 UTER/ADNX PROC-NONMAL EXC LEIO Surg LV PD PD 2.0 PER DIEM
513 3 UTER/ADNX PROC-NONMAL EXC LEIO Surg LV PD PD 2.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 32
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
513 4 UTER/ADNX PROC-NONMAL EXC LEIO Surg LV PD PD 2.0 PER DIEM
514 1 FEMALE REPROD RECONSTRUCT PROC Surg LV PD PD 1.9 PER DIEM
514 2 FEMALE REPROD RECONSTRUCT PROC Surg LV PD PD 1.9 PER DIEM
514 3 FEMALE REPROD RECONSTRUCT PROC Surg LV PD PD 1.9 PER DIEM
514 4 FEMALE REPROD RECONSTRUCT PROC Surg LV PD PD 1.9 PER DIEM
517 1 DILATION & CURET FOR NON-OB DX Surg LV PD PD 2.0 PER DIEM
517 2 DILATION & CURET FOR NON-OB DX Surg LV PD PD 2.0 PER DIEM
517 3 DILATION & CURET FOR NON-OB DX Surg LV PD PD 2.0 PER DIEM
517 4 DILATION & CURET FOR NON-OB DX Surg LV PD PD 2.0 PER DIEM
518 1 OTH FEMALE REPRO SYS&REL PROC Surg LV PD PD 1.8 PER DIEM
518 2 OTH FEMALE REPRO SYS&REL PROC Surg LV PD PD 1.9 PER DIEM
518 3 OTH FEMALE REPRO SYS&REL PROC Surg LV PD PD 2.5 PER DIEM
518 4 OTH FEMALE REPRO SYS&REL PROC Surg LV PD PD 6.0 PER DIEM
519 1 UTERINE/ADNEX PROC-LEIOMYOMA Med LV PD PD 3.0 PER DIEM
519 2 UTERINE/ADNEX PROC-LEIOMYOMA Med LV PD PD 3.0 PER DIEM
519 3 UTERINE/ADNEX PROC-LEIOMYOMA Med LV PD PD 5.0 PER DIEM
519 4 UTERINE/ADNEX PROC-LEIOMYOMA Med LV PD PD 5.0 PER DIEM
530 1 FEMALE REPRO SYST MALIG Med LV PD PD 7.0 PER DIEM
530 2 FEMALE REPRO SYST MALIG Med LV PD PD 7.0 PER DIEM
530 3 FEMALE REPRO SYST MALIG Med LV PD PD 7.0 PER DIEM
530 4 FEMALE REPRO SYST MALIG Med LV PD PD 7.0 PER DIEM
531 1 FEMALE REPRO SYST INFECTION Med LV PD PD 3.0 PER DIEM
531 2 FEMALE REPRO SYST INFECTION Med LV PD PD 3.0 PER DIEM
531 3 FEMALE REPRO SYST INFECTION Med LV PD PD 3.0 PER DIEM
531 4 FEMALE REPRO SYST INFECTION Med LV PD PD 3.0 PER DIEM
532 1 MENSTRUAL/OTH FEMALE REPROD DX Med LV PD PD 2.6 PER DIEM
532 2 MENSTRUAL/OTH FEMALE REPROD DX Med LV PD PD 2.6 PER DIEM
532 3 MENSTRUAL/OTH FEMALE REPROD DX Med LV PD PD 7.9 PER DIEM
532 4 MENSTRUAL/OTH FEMALE REPROD DX Med LV PD PD 7.9 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 33
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
540 1 CESAREAN DELIVERY Surg LV PD PD 4.0 PER DIEM
540 2 CESAREAN DELIVERY Surg LV PD PD 4.0 PER DIEM
540 3 CESAREAN DELIVERY Surg LV PD PD 4.0 PER DIEM
540 4 CESAREAN DELIVERY Surg LV PD PD 4.9 PER DIEM
541 1 VAGINAL DELIVERY W STERIL/D&C Surg LV PD PD 2.0 PER DIEM
541 2 VAGINAL DELIVERY W STERIL/D&C Surg LV PD PD 2.0 PER DIEM
541 3 VAGINAL DELIVERY W STERIL/D&C Surg LV PD PD 2.9 PER DIEM
541 4 VAGINAL DELIVERY W STERIL/D&C Surg LV PD PD 2.9 PER DIEM
542 1 VAG DEL W CMP PROC EX STER/D&C Med LV PD PD 1.7 PER DIEM
542 2 VAG DEL W CMP PROC EX STER/D&C Med LV PD PD 1.7 PER DIEM
542 3 VAG DEL W CMP PROC EX STER/D&C Med LV PD PD 3.0 PER DIEM
542 4 VAG DEL W CMP PROC EX STER/D&C Med LV PD PD 3.0 PER DIEM
544 1 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSISMed LV PD PD 2.0 PER DIEM
544 2 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSISMed LV PD PD 2.0 PER DIEM
544 3 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSISMed LV PD PD 2.0 PER DIEM
544 4 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSISMed LV PD PD 2.0 PER DIEM
545 1 ECTOPIC PREGNANCY PROC Med LV PD PD 1.9 PER DIEM
545 2 ECTOPIC PREGNANCY PROC Med LV PD PD 1.9 PER DIEM
545 3 ECTOPIC PREGNANCY PROC Med LV PD PD 1.9 PER DIEM
545 4 ECTOPIC PREGNANCY PROC Med LV PD PD 1.9 PER DIEM
546 1 OTH O.R. PROC-OB DX EXC DELIV Surg LV PD PD 3.0 PER DIEM
546 2 OTH O.R. PROC-OB DX EXC DELIV Surg LV PD PD 3.0 PER DIEM
546 3 OTH O.R. PROC-OB DX EXC DELIV Surg LV PD PD 3.0 PER DIEM
546 4 OTH O.R. PROC-OB DX EXC DELIV Surg LV PD PD 3.0 PER DIEM
560 1 VAGINAL DELIVERY Surg LV PD PD 1.8 PER DIEM
560 2 VAGINAL DELIVERY Surg LV PD PD 1.8 PER DIEM
560 3 VAGINAL DELIVERY Surg LV PD PD 1.8 PER DIEM
560 4 VAGINAL DELIVERY Surg LV PD PD 1.8 PER DIEM
561 1 POSTPARTUM & POST ABORTION DX Surg LV PD PD 4.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 34
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
561 2 POSTPARTUM & POST ABORTION DX Surg LV PD PD 4.0 PER DIEM
561 3 POSTPARTUM & POST ABORTION DX Surg LV PD PD 4.0 PER DIEM
561 4 POSTPARTUM & POST ABORTION DX Surg LV PD PD 4.0 PER DIEM
563 1 THREATENED ABORTION Med LV PD PD 3.5 PER DIEM
563 2 THREATENED ABORTION Med LV PD PD 3.5 PER DIEM
563 3 THREATENED ABORTION Med LV PD PD 3.5 PER DIEM
563 4 THREATENED ABORTION Med LV PD PD 3.5 PER DIEM
564 1 ABORT WO D&C Surg LV PD PD 2.0 PER DIEM
564 2 ABORT WO D&C Surg LV PD PD 2.0 PER DIEM
564 3 ABORT WO D&C Surg LV PD PD 2.0 PER DIEM
564 4 ABORT WO D&C Surg LV PD PD 2.0 PER DIEM
565 1 FALSE LABOR Med LV PD PD 1.9 PER DIEM
565 2 FALSE LABOR Med LV PD PD 1.9 PER DIEM
565 3 FALSE LABOR Med LV PD PD 1.9 PER DIEM
565 4 FALSE LABOR Med LV PD PD 1.9 PER DIEM
566 1 OTHER ANTEPARTUM DIAGNOSES Med LV PD PD 2.7 PER DIEM
566 2 OTHER ANTEPARTUM DIAGNOSES Med LV PD PD 2.7 PER DIEM
566 3 OTHER ANTEPARTUM DIAGNOSES Med LV PD PD 4.0 PER DIEM
566 4 OTHER ANTEPARTUM DIAGNOSES Med LV PD PD 4.0 PER DIEM
580 1 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERENot Covered NC NC NC NC Not Covered
580 2 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERENot Covered NC NC NC NC Not Covered
580 3 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERENot Covered NC NC NC NC Not Covered
580 4 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERENot Covered NC NC NC NC Not Covered
581 1 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERENot Covered NC NC NC NC Not Covered
581 2 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERENot Covered NC NC NC NC Not Covered
581 3 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERENot Covered NC NC NC NC Not Covered
581 4 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERENot Covered NC NC NC NC Not Covered
583 1 NEONATE WITH ECMO Not Covered NC NC NC NC Not Covered
583 2 NEONATE WITH ECMO Not Covered NC NC NC NC Not Covered
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 35
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
583 3 NEONATE WITH ECMO Not Covered NC NC NC NC Not Covered
583 4 NEONATE WITH ECMO Not Covered NC NC NC NC Not Covered
588 1 NEO BW <1500G W/MAJ PROC Not Covered NC NC NC NC Not Covered
588 2 NEO BW <1500G W/MAJ PROC Not Covered NC NC NC NC Not Covered
588 3 NEO BW <1500G W/MAJ PROC Not Covered NC NC NC NC Not Covered
588 4 NEO BW <1500G W/MAJ PROC Not Covered NC NC NC NC Not Covered
589 1 NEO BW <500G OR GA <24 WEEKS Not Covered NC NC NC NC Not Covered
589 2 NEO BW <500G OR GA <24 WEEKS Not Covered NC NC NC NC Not Covered
589 3 NEO BW <500G OR GA <24 WEEKS Not Covered NC NC NC NC Not Covered
589 4 NEO BW <500G OR GA <24 WEEKS Not Covered NC NC NC NC Not Covered
591 1 NEO BW 500-749G WO MAJ PROC Not Covered NC NC NC NC Not Covered
591 2 NEO BW 500-749G WO MAJ PROC Not Covered NC NC NC NC Not Covered
591 3 NEO BW 500-749G WO MAJ PROC Not Covered NC NC NC NC Not Covered
591 4 NEO BW 500-749G WO MAJ PROC Not Covered NC NC NC NC Not Covered
593 1 NEO BW 750-999G WO MAJ PROC Not Covered NC NC NC NC Not Covered
593 2 NEO BW 750-999G WO MAJ PROC Not Covered NC NC NC NC Not Covered
593 3 NEO BW 750-999G WO MAJ PROC Not Covered NC NC NC NC Not Covered
593 4 NEO BW 750-999G WO MAJ PROC Not Covered NC NC NC NC Not Covered
602 1 NEO BW 1000-1249G W RDS/MJ ANM Not Covered NC NC NC NC Not Covered
602 2 NEO BW 1000-1249G W RDS/MJ ANM Not Covered NC NC NC NC Not Covered
602 3 NEO BW 1000-1249G W RDS/MJ ANM Not Covered NC NC NC NC Not Covered
602 4 NEO BW 1000-1249G W RDS/MJ ANM Not Covered NC NC NC NC Not Covered
603 1 NEO BW 1000-1249G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
603 2 NEO BW 1000-1249G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
603 3 NEO BW 1000-1249G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
603 4 NEO BW 1000-1249G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
607 1 NEO BW 1250-1499G W RDS/MJ ANM Not Covered NC NC NC NC Not Covered
607 2 NEO BW 1250-1499G W RDS/MJ ANM Not Covered NC NC NC NC Not Covered
607 3 NEO BW 1250-1499G W RDS/MJ ANM Not Covered NC NC NC NC Not Covered
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 36
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
607 4 NEO BW 1250-1499G W RDS/MJ ANM Not Covered NC NC NC NC Not Covered
608 1 NEO BW 1250-1499G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
608 2 NEO BW 1250-1499G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
608 3 NEO BW 1250-1499G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
608 4 NEO BW 1250-1499G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
609 1 NEO BW 1500-2499G W/MAJ PROC Not Covered NC NC NC NC Not Covered
609 2 NEO BW 1500-2499G W/MAJ PROC Not Covered NC NC NC NC Not Covered
609 3 NEO BW 1500-2499G W/MAJ PROC Not Covered NC NC NC NC Not Covered
609 4 NEO BW 1500-2499G W/MAJ PROC Not Covered NC NC NC NC Not Covered
611 1 NEO BW 1500-1999G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
611 2 NEO BW 1500-1999G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
611 3 NEO BW 1500-1999G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
611 4 NEO BW 1500-1999G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
612 1 NEO BW 1500-1999G W RDS/MJ RES Not Covered NC NC NC NC Not Covered
612 2 NEO BW 1500-1999G W RDS/MJ RES Not Covered NC NC NC NC Not Covered
612 3 NEO BW 1500-1999G W RDS/MJ RES Not Covered NC NC NC NC Not Covered
612 4 NEO BW 1500-1999G W RDS/MJ RES Not Covered NC NC NC NC Not Covered
613 1 NEO BW 1500-1999G PERIN INFEC Not Covered NC NC NC NC Not Covered
613 2 NEO BW 1500-1999G PERIN INFEC Not Covered NC NC NC NC Not Covered
613 3 NEO BW 1500-1999G PERIN INFEC Not Covered NC NC NC NC Not Covered
613 4 NEO BW 1500-1999G PERIN INFEC Not Covered NC NC NC NC Not Covered
614 1 NEO BW 1500-1999G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
614 2 NEO BW 1500-1999G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
614 3 NEO BW 1500-1999G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
614 4 NEO BW 1500-1999G W/WO OTH SIG Not Covered NC NC NC NC Not Covered
621 1 NEO BW 2000-2499G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
621 2 NEO BW 2000-2499G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
621 3 NEO BW 2000-2499G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
621 4 NEO BW 2000-2499G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 37
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
622 1 NEO BW 2000-2499G W RDS/MJ RES Not Covered NC NC NC NC Not Covered
622 2 NEO BW 2000-2499G W RDS/MJ RES Not Covered NC NC NC NC Not Covered
622 3 NEO BW 2000-2499G W RDS/MJ RES Not Covered NC NC NC NC Not Covered
622 4 NEO BW 2000-2499G W RDS/MJ RES Not Covered NC NC NC NC Not Covered
623 1 NEO BW 2000-2499G PERIN INFEC Not Covered NC NC NC NC Not Covered
623 2 NEO BW 2000-2499G PERIN INFEC Not Covered NC NC NC NC Not Covered
623 3 NEO BW 2000-2499G PERIN INFEC Not Covered NC NC NC NC Not Covered
623 4 NEO BW 2000-2499G PERIN INFEC Not Covered NC NC NC NC Not Covered
625 1 NEO BW 2000-2499G OTH SIG DX Not Covered NC NC NC NC Not Covered
625 2 NEO BW 2000-2499G OTH SIG DX Not Covered NC NC NC NC Not Covered
625 3 NEO BW 2000-2499G OTH SIG DX Not Covered NC NC NC NC Not Covered
625 4 NEO BW 2000-2499G OTH SIG DX Not Covered NC NC NC NC Not Covered
626 1 NEO BW 2000-2499G NNB/OTH PROB Not Covered NC NC NC NC Not Covered
626 2 NEO BW 2000-2499G NNB/OTH PROB Not Covered NC NC NC NC Not Covered
626 3 NEO BW 2000-2499G NNB/OTH PROB Not Covered NC NC NC NC Not Covered
626 4 NEO BW 2000-2499G NNB/OTH PROB Not Covered NC NC NC NC Not Covered
630 1 NEO BW >2499G MAJ CV PROC Not Covered NC NC NC NC Not Covered
630 2 NEO BW >2499G MAJ CV PROC Not Covered NC NC NC NC Not Covered
630 3 NEO BW >2499G MAJ CV PROC Not Covered NC NC NC NC Not Covered
630 4 NEO BW >2499G MAJ CV PROC Not Covered NC NC NC NC Not Covered
631 1 NEO BW >2499G OTH MAJ PROC Not Covered NC NC NC NC Not Covered
631 2 NEO BW >2499G OTH MAJ PROC Not Covered NC NC NC NC Not Covered
631 3 NEO BW >2499G OTH MAJ PROC Not Covered NC NC NC NC Not Covered
631 4 NEO BW >2499G OTH MAJ PROC Not Covered NC NC NC NC Not Covered
633 1 NEO BW >2499G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
633 2 NEO BW >2499G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
633 3 NEO BW >2499G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
633 4 NEO BW >2499G W/MAJ ANOM Not Covered NC NC NC NC Not Covered
634 1 NEO BW >2499G W RDS/MAJ RESP Not Covered NC NC NC NC Not Covered
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 38
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
634 2 NEO BW >2499G W RDS/MAJ RESP Not Covered NC NC NC NC Not Covered
634 3 NEO BW >2499G W RDS/MAJ RESP Not Covered NC NC NC NC Not Covered
634 4 NEO BW >2499G W RDS/MAJ RESP Not Covered NC NC NC NC Not Covered
636 1 NEO BW >2499G PERIN INFECT Not Covered NC NC NC NC Not Covered
636 2 NEO BW >2499G PERIN INFECT Not Covered NC NC NC NC Not Covered
636 3 NEO BW >2499G PERIN INFECT Not Covered NC NC NC NC Not Covered
636 4 NEO BW >2499G PERIN INFECT Not Covered NC NC NC NC Not Covered
639 1 NEO BW >2499G OTH SIG COND Not Covered NC NC NC NC Not Covered
639 2 NEO BW >2499G OTH SIG COND Not Covered NC NC NC NC Not Covered
639 3 NEO BW >2499G OTH SIG COND Not Covered NC NC NC NC Not Covered
639 4 NEO BW >2499G OTH SIG COND Not Covered NC NC NC NC Not Covered
640 1 NEO BW >2499G NORM NB/OTH PROB Not Covered NC NC NC NC Not Covered
640 2 NEO BW >2499G NORM NB/OTH PROB Not Covered NC NC NC NC Not Covered
640 3 NEO BW >2499G NORM NB/OTH PROB Not Covered NC NC NC NC Not Covered
640 4 NEO BW >2499G NORM NB/OTH PROB Not Covered NC NC NC NC Not Covered
650 1 SPLENECTOMY Surg LV PD PD 3.7 PER DIEM
650 2 SPLENECTOMY Surg LV PD PD 3.7 PER DIEM
650 3 SPLENECTOMY Surg LV PD PD 6.0 PER DIEM
650 4 SPLENECTOMY Surg LV PD PD 6.0 PER DIEM
651 1 OTHER PROCEDURES OF BLOOD Surg LV PD PD 3.5 PER DIEM
651 2 OTHER PROCEDURES OF BLOOD Surg LV PD PD 3.5 PER DIEM
651 3 OTHER PROCEDURES OF BLOOD Surg 1.6918 17,726.58 590.97 4.9 APR-DRG
651 4 OTHER PROCEDURES OF BLOOD Surg LV PD PD 5.0 PER DIEM
660 1 MAJ HEMATOLOGIC/IMMUNOL DX Med LV PD PD 6.0 PER DIEM
660 2 MAJ HEMATOLOGIC/IMMUNOL DX Med LV PD PD 6.0 PER DIEM
660 3 MAJ HEMATOLOGIC/IMMUNOL DX Med LV PD PD 6.0 PER DIEM
660 4 MAJ HEMATOLOGIC/IMMUNOL DX Med LV PD PD 6.0 PER DIEM
661 1 COAGULATION/PLATELET DISORDER Med LV PD PD 2.9 PER DIEM
661 2 COAGULATION/PLATELET DISORDER Med LV PD PD 2.9 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 39
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
661 3 COAGULATION/PLATELET DISORDER Med LV PD PD 2.9 PER DIEM
661 4 COAGULATION/PLATELET DISORDER Med LV PD PD 2.9 PER DIEM
662 1 SICKLE CELL ANEMIA CRISIS Med LV PD PD 5.0 PER DIEM
662 2 SICKLE CELL ANEMIA CRISIS Med LV PD PD 5.0 PER DIEM
662 3 SICKLE CELL ANEMIA CRISIS Med LV PD PD 5.0 PER DIEM
662 4 SICKLE CELL ANEMIA CRISIS Med LV PD PD 5.0 PER DIEM
663 1 OTHER ANEMIA/BLOOD DISORD Med 0.6319 17,726.58 590.97 2.4 APR-DRG
663 2 OTHER ANEMIA/BLOOD DISORD Med 0.6319 17,726.58 590.97 2.4 APR-DRG
663 3 OTHER ANEMIA/BLOOD DISORD Med LV PD PD 5.0 PER DIEM
663 4 OTHER ANEMIA/BLOOD DISORD Med LV PD PD 8.0 PER DIEM
680 1 MAJ PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD PD 4.0 PER DIEM
680 2 MAJ PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD PD 6.0 PER DIEM
680 3 MAJ PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD PD 10.0 PER DIEM
680 4 MAJ PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD PD 20.0 PER DIEM
681 1 OTH PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD PD 2.9 PER DIEM
681 2 OTH PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD PD 3.9 PER DIEM
681 3 OTH PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD PD 4.0 PER DIEM
681 4 OTH PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD PD 10.0 PER DIEM
690 1 ACUTE LEUKEMIA Med LV PD PD 4.7 PER DIEM
690 2 ACUTE LEUKEMIA Med LV PD PD 6.9 PER DIEM
690 3 ACUTE LEUKEMIA Med LV PD PD 8.0 PER DIEM
690 4 ACUTE LEUKEMIA Med LV PD PD 14.0 PER DIEM
691 1 LYMPH/MYELO/NON-AC LEUK Med LV PD PD 3.6 PER DIEM
691 2 LYMPH/MYELO/NON-AC LEUK Med LV PD PD 6.7 PER DIEM
691 3 LYMPH/MYELO/NON-AC LEUK Med LV PD PD 9.7 PER DIEM
691 4 LYMPH/MYELO/NON-AC LEUK Med LV PD PD 12.0 PER DIEM
692 1 RADIOTHERAPY Med LV PD PD 4.0 PER DIEM
692 2 RADIOTHERAPY Med LV PD PD 4.0 PER DIEM
692 3 RADIOTHERAPY Med LV PD PD 4.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 40
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
692 4 RADIOTHERAPY Med LV PD PD 4.0 PER DIEM
693 1 CHEMOTHERAPY Med LV PD PD 4.0 PER DIEM
693 2 CHEMOTHERAPY Med LV PD PD 4.0 PER DIEM
693 3 CHEMOTHERAPY Med LV PD PD 4.0 PER DIEM
693 4 CHEMOTHERAPY Med LV PD PD 4.0 PER DIEM
694 1 LYMPH & OTH MALIG & NEOPL Med LV PD PD 5.0 PER DIEM
694 2 LYMPH & OTH MALIG & NEOPL Med LV PD PD 5.0 PER DIEM
694 3 LYMPH & OTH MALIG & NEOPL Med LV PD PD 7.8 PER DIEM
694 4 LYMPH & OTH MALIG & NEOPL Med LV PD PD 7.8 PER DIEM
710 1 INFECT & PARASITIC DIS W PROC Surg 0.7960 17,726.58 902.23 4.0 APR-DRG
710 2 INFECT & PARASITIC DIS W PROC Surg 0.7960 17,726.58 902.23 4.0 APR-DRG
710 3 INFECT & PARASITIC DIS W PROC Surg 0.7960 17,726.58 902.23 4.0 APR-DRG
710 4 INFECT & PARASITIC DIS W PROC Surg 0.7960 17,726.58 902.23 4.0 APR-DRG
711 1 POSTOP/TRAUM/DEV INFECT W PROC Med 0.6287 17,726.58 738.57 3.9 APR-DRG
711 2 POSTOP/TRAUM/DEV INFECT W PROC Med 0.6287 17,726.58 738.57 3.9 APR-DRG
711 3 POSTOP/TRAUM/DEV INFECT W PROC Med LV PD PD 6.0 PER DIEM
711 4 POSTOP/TRAUM/DEV INFECT W PROC Med LV PD PD 6.0 PER DIEM
720 1 SEPTICEMIA & DISSEM INFECT Med 0.8260 17,726.58 832.58 4.7 APR-DRG
720 2 SEPTICEMIA & DISSEM INFECT Med 0.8260 17,726.58 832.58 4.7 APR-DRG
720 3 SEPTICEMIA & DISSEM INFECT Med 1.7452 17,726.58 1,234.12 5.9 APR-DRG
720 4 SEPTICEMIA & DISSEM INFECT Med 1.7452 17,726.58 1,234.12 5.9 APR-DRG
721 1 POST-OP/POST-TRAUM/DEV INFECT Med 0.4772 17,726.58 590.97 3.2 APR-DRG
721 2 POST-OP/POST-TRAUM/DEV INFECT Med 0.4772 17,726.58 590.97 3.2 APR-DRG
721 3 POST-OP/POST-TRAUM/DEV INFECT Med 0.4772 17,726.58 590.97 3.2 APR-DRG
721 4 POST-OP/POST-TRAUM/DEV INFECT Med 0.4772 17,726.58 590.97 3.2 APR-DRG
722 1 FEVER Med LV PD PD 3.0 PER DIEM
722 2 FEVER Med LV PD PD 3.0 PER DIEM
722 3 FEVER Med LV PD PD 4.0 PER DIEM
722 4 FEVER Med LV PD PD 4.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 41
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
723 1 VIRAL ILLNESS Med LV PD PD 3.0 PER DIEM
723 2 VIRAL ILLNESS Med LV PD PD 3.0 PER DIEM
723 3 VIRAL ILLNESS Med LV PD PD 3.0 PER DIEM
723 4 VIRAL ILLNESS Med LV PD PD 3.0 PER DIEM
724 1 OTH INFECT & PARASITIC DIS Med 0.6917 17,726.58 590.97 3.2 APR-DRG
724 2 OTH INFECT & PARASITIC DIS Med 0.6917 17,726.58 590.97 3.2 APR-DRG
724 3 OTH INFECT & PARASITIC DIS Med 0.6996 17,726.58 712.88 4.6 APR-DRG
724 4 OTH INFECT & PARASITIC DIS Med 0.6996 17,726.58 712.88 4.6 APR-DRG
740 1 MENTAL ILLNESS DX W PROC Psych LV PD PD 5.5 PER DIEM
740 2 MENTAL ILLNESS DX W PROC Psych LV PD PD 5.5 PER DIEM
740 3 MENTAL ILLNESS DX W PROC Psych LV PD PD 5.5 PER DIEM
740 4 MENTAL ILLNESS DX W PROC Psych LV PD PD 5.5 PER DIEM
750 1 SCHIZOPHRENIA Psych LV PD PD 10.0 PER DIEM
750 2 SCHIZOPHRENIA Psych LV PD PD 10.0 PER DIEM
750 3 SCHIZOPHRENIA Psych LV PD PD 10.0 PER DIEM
750 4 SCHIZOPHRENIA Psych LV PD PD 10.0 PER DIEM
751 1 MAJOR DEPRESSIVE DISORDER Psych LV PD PD 14.4 PER DIEM
751 2 MAJOR DEPRESSIVE DISORDER Psych LV PD PD 14.4 PER DIEM
751 3 MAJOR DEPRESSIVE DISORDER Psych LV PD PD 14.4 PER DIEM
751 4 MAJOR DEPRESSIVE DISORDER Psych LV PD PD 14.4 PER DIEM
752 1 DIS PERSONALITY/IMPULSE CONTRL Psych LV PD PD 0.0 PER DIEM
752 2 DIS PERSONALITY/IMPULSE CONTRL Psych LV PD PD 0.0 PER DIEM
752 3 DIS PERSONALITY/IMPULSE CONTRL Psych LV PD PD 0.0 PER DIEM
752 4 DIS PERSONALITY/IMPULSE CONTRL Psych LV PD PD 0.0 PER DIEM
753 1 BIPOLAR DISORDERS Psych LV PD PD 7.0 PER DIEM
753 2 BIPOLAR DISORDERS Psych LV PD PD 7.0 PER DIEM
753 3 BIPOLAR DISORDERS Psych LV PD PD 7.0 PER DIEM
753 4 BIPOLAR DISORDERS Psych LV PD PD 7.0 PER DIEM
754 1 DEPRESSION EXC MAJ DEPRESSV DX Psych LV PD PD 3.9 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 42
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
754 2 DEPRESSION EXC MAJ DEPRESSV DX Psych LV PD PD 3.9 PER DIEM
754 3 DEPRESSION EXC MAJ DEPRESSV DX Psych LV PD PD 3.9 PER DIEM
754 4 DEPRESSION EXC MAJ DEPRESSV DX Psych LV PD PD 3.9 PER DIEM
755 1 ADJUST DIS EXC DEPRESSIVE DX Psych LV PD PD 0.0 PER DIEM
755 2 ADJUST DIS EXC DEPRESSIVE DX Psych LV PD PD 0.0 PER DIEM
755 3 ADJUST DIS EXC DEPRESSIVE DX Psych LV PD PD 0.0 PER DIEM
755 4 ADJUST DIS EXC DEPRESSIVE DX Psych LV PD PD 0.0 PER DIEM
756 1 ACUTE ANXIETY & DELIRIUM Psych LV PD PD 2.0 PER DIEM
756 2 ACUTE ANXIETY & DELIRIUM Psych LV PD PD 2.0 PER DIEM
756 3 ACUTE ANXIETY & DELIRIUM Psych LV PD PD 2.0 PER DIEM
756 4 ACUTE ANXIETY & DELIRIUM Psych LV PD PD 2.0 PER DIEM
757 1 ORGANIC MENTAL HEALTH DIS Psych LV PD PD 5.0 PER DIEM
757 2 ORGANIC MENTAL HEALTH DIS Psych LV PD PD 5.0 PER DIEM
757 3 ORGANIC MENTAL HEALTH DIS Psych LV PD PD 5.0 PER DIEM
757 4 ORGANIC MENTAL HEALTH DIS Psych LV PD PD 5.0 PER DIEM
758 1 CHILDHOOD BEHAVIORAL DIS Not Covered NC NC NC NC Not Covered
758 2 CHILDHOOD BEHAVIORAL DIS Not Covered NC NC NC NC Not Covered
758 3 CHILDHOOD BEHAVIORAL DIS Not Covered NC NC NC NC Not Covered
758 4 CHILDHOOD BEHAVIORAL DIS Not Covered NC NC NC NC Not Covered
759 1 EATING DISORDERS Med LV PD PD 26.7 PER DIEM
759 2 EATING DISORDERS Med LV PD PD 26.7 PER DIEM
759 3 EATING DISORDERS Med LV PD PD 26.7 PER DIEM
759 4 EATING DISORDERS Med LV PD PD 26.7 PER DIEM
760 1 OTH MENTAL HEALTH DISORDER Psych LV PD PD 0.0 PER DIEM
760 2 OTH MENTAL HEALTH DISORDER Psych LV PD PD 0.0 PER DIEM
760 3 OTH MENTAL HEALTH DISORDER Psych LV PD PD 4.5 PER DIEM
760 4 OTH MENTAL HEALTH DISORDER Psych LV PD PD 4.5 PER DIEM
770 1 DRUG & ALCOHOL ABUSE - LAMA Chem LV PD PD 2.0 PER DIEM
770 2 DRUG & ALCOHOL ABUSE - LAMA Chem LV PD PD 2.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 43
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
770 3 DRUG & ALCOHOL ABUSE - LAMA Chem LV PD PD 2.0 PER DIEM
770 4 DRUG & ALCOHOL ABUSE - LAMA Chem LV PD PD 2.0 PER DIEM
772 1 ALCOHOL/DRUG DEP W REHAB Chem LV PD PD 23.0 PER DIEM
772 2 ALCOHOL/DRUG DEP W REHAB Chem LV PD PD 23.0 PER DIEM
772 3 ALCOHOL/DRUG DEP W REHAB Chem LV PD PD 23.0 PER DIEM
772 4 ALCOHOL/DRUG DEP W REHAB Chem LV PD PD 23.0 PER DIEM
773 1 OPIOID ABUSE & DEPENDENCE Chem LV PD PD 7.3 PER DIEM
773 2 OPIOID ABUSE & DEPENDENCE Chem LV PD PD 7.3 PER DIEM
773 3 OPIOID ABUSE & DEPENDENCE Chem LV PD PD 11.0 PER DIEM
773 4 OPIOID ABUSE & DEPENDENCE Chem LV PD PD 11.0 PER DIEM
774 1 COCAINE ABUSE & DEPENDENCE Chem LV PD PD 3.0 PER DIEM
774 2 COCAINE ABUSE & DEPENDENCE Chem LV PD PD 3.5 PER DIEM
774 3 COCAINE ABUSE & DEPENDENCE Chem LV PD PD 3.5 PER DIEM
774 4 COCAINE ABUSE & DEPENDENCE Chem LV PD PD 3.7 PER DIEM
775 1 ALCOHOL ABUSE & DEPENDENCE Chem LV PD PD 4.5 PER DIEM
775 2 ALCOHOL ABUSE & DEPENDENCE Chem LV PD PD 5.5 PER DIEM
775 3 ALCOHOL ABUSE & DEPENDENCE Chem LV PD PD 5.5 PER DIEM
775 4 ALCOHOL ABUSE & DEPENDENCE Chem LV PD PD 11.0 PER DIEM
776 1 OTHER DRUG ABUSE & DEPEND Chem LV PD PD 4.0 PER DIEM
776 2 OTHER DRUG ABUSE & DEPEND Chem LV PD PD 4.0 PER DIEM
776 3 OTHER DRUG ABUSE & DEPEND Chem LV PD PD 4.0 PER DIEM
776 4 OTHER DRUG ABUSE & DEPEND Chem LV PD PD 4.0 PER DIEM
791 1 O.R. PROC OTH COMP TREAT Surg LV PD PD 5.0 PER DIEM
791 2 O.R. PROC OTH COMP TREAT Surg LV PD PD 5.0 PER DIEM
791 3 O.R. PROC OTH COMP TREAT Surg LV PD PD 5.0 PER DIEM
791 4 O.R. PROC OTH COMP TREAT Surg LV PD PD 5.0 PER DIEM
811 1 ALLERGIC REACTIONS Med LV PD PD 1.9 PER DIEM
811 2 ALLERGIC REACTIONS Med LV PD PD 1.9 PER DIEM
811 3 ALLERGIC REACTIONS Med LV PD PD 3.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 44
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
811 4 ALLERGIC REACTIONS Med LV PD PD 3.0 PER DIEM
812 1 POISONING MEDICINAL AGENT Med 0.3381 17,726.58 590.97 1.3 APR-DRG
812 2 POISONING MEDICINAL AGENT Med 0.3381 17,726.58 590.97 1.3 APR-DRG
812 3 POISONING MEDICINAL AGENT Med 0.5728 17,726.58 590.97 2.1 APR-DRG
812 4 POISONING MEDICINAL AGENT Med 0.5728 17,726.58 590.97 2.1 APR-DRG
813 1 OTH COMP OF TREATMENT Surg 0.6277 17,726.58 741.31 2.3 APR-DRG
813 2 OTH COMP OF TREATMENT Surg 0.6277 17,726.58 741.31 2.3 APR-DRG
813 3 OTH COMP OF TREATMENT Surg 1.6460 17,726.58 1,141.95 3.8 APR-DRG
813 4 OTH COMP OF TREATMENT Surg 1.6460 17,726.58 1,141.95 3.8 APR-DRG
815 1 OTH INJ/ POISON/TOXIC DX Med 0.4338 17,726.58 590.97 1.7 APR-DRG
815 2 OTH INJ/ POISON/TOXIC DX Med 0.4728 17,726.58 590.97 2.1 APR-DRG
815 3 OTH INJ/ POISON/TOXIC DX Med 0.5541 17,726.58 590.97 2.6 APR-DRG
815 4 OTH INJ/ POISON/TOXIC DX Med LV PD PD 3.8 PER DIEM
816 1 TOXIC EFFECTS NON-MEDC SUBST Med LV PD PD 3.0 PER DIEM
816 2 TOXIC EFFECTS NON-MEDC SUBST Med LV PD PD 3.0 PER DIEM
816 3 TOXIC EFFECTS NON-MEDC SUBST Med LV PD PD 3.0 PER DIEM
816 4 TOXIC EFFECTS NON-MEDC SUBST Med LV PD PD 3.0 PER DIEM
841 1 EXTEN 3RD DEG BURN W GRAFT Surg LV PD PD 58.0 PER DIEM
841 2 EXTEN 3RD DEG BURN W GRAFT Surg LV PD PD 58.0 PER DIEM
841 3 EXTEN 3RD DEG BURN W GRAFT Surg LV PD PD 58.0 PER DIEM
841 4 EXTEN 3RD DEG BURN W GRAFT Surg LV PD PD 58.0 PER DIEM
842 1 FULL THICK BURNS W GRAFT Surg 1.2373 28,425.48 1,504.76 8.0 APR-DRG
842 2 FULL THICK BURNS W GRAFT Surg 1.2373 28,425.48 1,504.76 8.0 APR-DRG
842 3 FULL THICK BURNS W GRAFT Surg LV PD PD 27.0 PER DIEM
842 4 FULL THICK BURNS W GRAFT Surg LV PD PD 27.0 PER DIEM
843 1 EXT 3RD/FULL THCK BURN WO GRFT Med 0.4267 17,726.58 590.97 3.5 APR-DRG
843 2 EXT 3RD/FULL THCK BURN WO GRFT Med LV PD PD 3.5 PER DIEM
843 3 EXT 3RD/FULL THCK BURN WO GRFT Med LV PD PD 9.0 PER DIEM
843 4 EXT 3RD/FULL THCK BURN WO GRFT Med LV PD PD 9.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 45
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
844 1 PART THICK BURNS W/WO GRAFT Med 0.3962 17,726.58 641.64 2.9 APR-DRG
844 2 PART THICK BURNS W/WO GRAFT Med 0.3962 17,726.58 641.64 2.9 APR-DRG
844 3 PART THICK BURNS W/WO GRAFT Med 0.5133 34,075.40 2,093.79 3.8 APR-DRG
844 4 PART THICK BURNS W/WO GRAFT Med 0.5133 34,075.40 2,093.79 3.8 APR-DRG
850 1 PROC W DX REHAB Rehab LV PD PD 9.0 PER DIEM
850 2 PROC W DX REHAB Rehab LV PD PD 9.0 PER DIEM
850 3 PROC W DX REHAB Rehab LV PD PD 9.0 PER DIEM
850 4 PROC W DX REHAB Rehab LV PD PD 9.0 PER DIEM
860 1 REHABILITATION Rehab LV PD PD 14.5 PER DIEM
860 2 REHABILITATION Rehab LV PD PD 14.5 PER DIEM
860 3 REHABILITATION Rehab LV PD PD 14.5 PER DIEM
860 4 REHABILITATION Rehab LV PD PD 14.5 PER DIEM
861 1 SIGNS/SYMPTOMS/OTH FACTORS Med 0.3891 17,726.58 590.97 2.2 APR-DRG
861 2 SIGNS/SYMPTOMS/OTH FACTORS Med 0.7246 17,726.58 602.80 2.9 APR-DRG
861 3 SIGNS/SYMPTOMS/OTH FACTORS Med LV PD PD 3.0 PER DIEM
861 4 SIGNS/SYMPTOMS/OTH FACTORS Med LV PD PD 4.0 PER DIEM
862 1 OTH AFTERCARE & CONVALES Med LV PD PD 0.0 PER DIEM
862 2 OTH AFTERCARE & CONVALES Med LV PD PD 2.0 PER DIEM
862 3 OTH AFTERCARE & CONVALES Med LV PD PD 2.0 PER DIEM
862 4 OTH AFTERCARE & CONVALES Med LV PD PD 3.0 PER DIEM
863 1 NEONATAL AFTERCARE Med LV PD PD 0.0 PER DIEM
863 2 NEONATAL AFTERCARE Med LV PD PD 0.0 PER DIEM
863 3 NEONATAL AFTERCARE Med LV PD PD 0.0 PER DIEM
863 4 NEONATAL AFTERCARE Med LV PD PD 0.0 PER DIEM
890 1 HIV W MULT MAJOR HIV REL CONDS Med LV PD PD 14.9 PER DIEM
890 2 HIV W MULT MAJOR HIV REL CONDS Med LV PD PD 14.9 PER DIEM
890 3 HIV W MULT MAJOR HIV REL CONDS Med LV PD PD 14.9 PER DIEM
890 4 HIV W MULT MAJOR HIV REL CONDS Med LV PD PD 14.9 PER DIEM
892 1 HIV W MAJOR HIV REL COND Surg LV PD PD 10.0 PER DIEM
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 46
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
892 2 HIV W MAJOR HIV REL COND Surg LV PD PD 12.0 PER DIEM
892 3 HIV W MAJOR HIV REL COND Surg LV PD PD 24.5 PER DIEM
892 4 HIV W MAJOR HIV REL COND Surg LV PD PD 30.0 PER DIEM
893 1 HIV W MULT SIGN HIV REL CONDS Med LV PD PD 4.0 PER DIEM
893 2 HIV W MULT SIGN HIV REL CONDS Med LV PD PD 10.0 PER DIEM
893 3 HIV W MULT SIGN HIV REL CONDS Med LV PD PD 17.0 PER DIEM
893 4 HIV W MULT SIGN HIV REL CONDS Med LV PD PD 20.0 PER DIEM
894 1 HIV W/WO ONE SIGNIF HIV COND Med LV PD PD 5.0 PER DIEM
894 2 HIV W/WO ONE SIGNIF HIV COND Med LV PD PD 5.0 PER DIEM
894 3 HIV W/WO ONE SIGNIF HIV COND Med LV PD PD 5.0 PER DIEM
894 4 HIV W/WO ONE SIGNIF HIV COND Med LV PD PD 5.0 PER DIEM
910 1 CRANIOTOMY MULT SIG TRAUMA Surg LV PD PD 9.3 PER DIEM
910 2 CRANIOTOMY MULT SIG TRAUMA Surg LV PD PD 9.3 PER DIEM
910 3 CRANIOTOMY MULT SIG TRAUMA Surg 6.0469 98,284.31 4,884.06 23.0 APR-DRG
910 4 CRANIOTOMY MULT SIG TRAUMA Surg 6.0469 98,284.31 4,884.06 23.0 APR-DRG
911 1 EXT ABD/THORAC PROC FOR MST Surg LV PD PD 14.0 PER DIEM
911 2 EXT ABD/THORAC PROC FOR MST Surg LV PD PD 14.0 PER DIEM
911 3 EXT ABD/THORAC PROC FOR MST Surg LV PD PD 14.0 PER DIEM
911 4 EXT ABD/THORAC PROC FOR MST Surg LV PD PD 14.0 PER DIEM
912 1 MUSCKL/OTH PROC MULT SIG TRAUM Surg 1.2744 18,377.32 1,311.09 4.5 APR-DRG
912 2 MUSCKL/OTH PROC MULT SIG TRAUM Surg 1.9918 42,099.91 2,876.60 6.0 APR-DRG
912 3 MUSCKL/OTH PROC MULT SIG TRAUM Surg 3.0113 29,190.09 2,339.58 6.1 APR-DRG
912 4 MUSCKL/OTH PROC MULT SIG TRAUM Surg 3.8671 72,975.40 3,405.56 7.9 APR-DRG
930 1 MULTIPLE SIG TRAUMA WO PROC Med 0.7479 17,726.58 896.08 3.1 APR-DRG
930 2 MULTIPLE SIG TRAUMA WO PROC Med 0.7479 17,726.58 896.08 3.6 APR-DRG
930 3 MULTIPLE SIG TRAUMA WO PROC Med 0.9181 17,726.58 1,133.74 3.6 APR-DRG
930 4 MULTIPLE SIG TRAUMA WO PROC Med 3.8127 49,795.99 1,746.61 5.7 APR-DRG
950 1 EXTENSIVE PROC UNREL PDX Surg 1.3164 28,080.88 1,460.21 5.0 APR-DRG
950 2 EXTENSIVE PROC UNREL PDX Surg 1.3164 28,080.88 1,460.21 5.0 APR-DRG
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 47
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2014
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
Low Outlier
Threshold
Avg
LOS
Paid
Using
950 3 EXTENSIVE PROC UNREL PDX Surg 1.3164 28,080.88 1,460.21 13.9 APR-DRG
950 4 EXTENSIVE PROC UNREL PDX Surg 6.9570 119,290.79 5,972.18 13.9 APR-DRG
951 1 MOD EXTENSIVE PROC-UNREL PDX Surg 1.0220 28,739.83 1,679.91 3.2 APR-DRG
951 2 MOD EXTENSIVE PROC-UNREL PDX Surg 1.0220 28,739.83 1,679.91 3.2 APR-DRG
951 3 MOD EXTENSIVE PROC-UNREL PDX Surg 2.9164 28,685.16 1,897.18 5.2 APR-DRG
951 4 MOD EXTENSIVE PROC-UNREL PDX Surg 2.9164 28,685.16 1,897.18 5.2 APR-DRG
952 1 NONEXTENSIVE PROC-UNREL PDX Surg 0.7850 17,726.58 753.60 3.4 APR-DRG
952 2 NONEXTENSIVE PROC-UNREL PDX Surg 0.7850 17,726.58 753.60 3.4 APR-DRG
952 3 NONEXTENSIVE PROC-UNREL PDX Surg LV PD PD 9.0 PER DIEM
952 4 NONEXTENSIVE PROC-UNREL PDX Surg LV PD PD 9.0 PER DIEM
955 1 PDX INVALID AS DISCHARGE DX Not Covered NC NC NC NC Not Covered
955 2 PDX INVALID AS DISCHARGE DX Not Covered NC NC NC NC Not Covered
955 3 PDX INVALID AS DISCHARGE DX Not Covered NC NC NC NC Not Covered
955 4 PDX INVALID AS DISCHARGE DX Not Covered NC NC NC NC Not Covered
956 1 UNGROUPABLE Not Covered NC NC NC NC Not Covered
956 2 UNGROUPABLE Not Covered NC NC NC NC Not Covered
956 3 UNGROUPABLE Not Covered NC NC NC NC Not Covered
956 4 UNGROUPABLE Not Covered NC NC NC NC Not Covered
L&I uses APR-DRG Version 31.0 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 48