Facilities Fee Schedule APR-DRG Assignment Effective July ... · Facilities Fee Schedule APR-DRG...

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Facilities Fee Schedule APR-DRG Assignment Effective July 1, 2016 APR-DRG Assignment Effective for Dates of Service on or After July 1, 2016 To Skip The Keys & Go To The Fees Click Here L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 1

Transcript of Facilities Fee Schedule APR-DRG Assignment Effective July ... · Facilities Fee Schedule APR-DRG...

Facilities Fee Schedule

APR-DRG Assignment

Effective July 1, 2016

APR-DRG Assignment

Effective for Dates of Service on or After

July 1, 2016

To Skip The Keys

&

Go To The Fees

Click Here

L&I uses APR-DRG Version 31 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, 2016

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 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 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, 2016

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 stayHow 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

rate, this value is used to determine payment amounts for

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 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, 2016

L&I uses APR-DRG Version 31 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, 2016

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

056 4 BRAIN CONTUSION/LACERATION Med 0.7171 17,726.58 821.59 3.3 APR-DRG

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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 DX Med LV PD PD 1.5 PER DIEM

115 2 OTH EAR NOSE MOUTH THROAT CRAN DX Med LV PD PD 2.3 PER DIEM

115 3 OTH EAR NOSE MOUTH THROAT CRAN DX Med LV PD PD 3.0 PER DIEM

115 4 OTH EAR NOSE MOUTH THROAT CRAN DX Med 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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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

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Facilities Fee Schedule

APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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Facilities Fee Schedule

APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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Facilities Fee Schedule

APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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

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Facilities Fee Schedule

APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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Facilities Fee Schedule

APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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 PROCEDURE Med LV PD PD 5.0 PER DIEM

252 2 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDURE Med LV PD PD 5.0 PER DIEM

252 3 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDURE Med LV PD PD 5.0 PER DIEM

252 4 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDURE Med 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

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

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Facilities Fee Schedule

APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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

L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 19

Facilities Fee Schedule

APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 20

Facilities Fee Schedule

APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 21

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APR-DRG Assignment

Effective July 1, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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 DIAGNOSIS Med LV PD PD 2.0 PER DIEM

544 2 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSIS Med LV PD PD 2.0 PER DIEM

544 3 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSIS Med LV PD PD 2.0 PER DIEM

544 4 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSIS Med LV PD PD 2.0 PER DIEM

545 1 ECTOPIC PREGNANCY PROC Med LV PD PD 1.9 PER DIEM

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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 HERE Not Covered NC NC NC NC Not Covered

580 2 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE Not Covered NC NC NC NC Not Covered

580 3 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE Not Covered NC NC NC NC Not Covered

580 4 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE Not Covered NC NC NC NC Not Covered

581 1 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERE Not Covered NC NC NC NC Not Covered

581 2 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERE Not Covered NC NC NC NC Not Covered

581 3 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERE Not Covered NC NC NC NC Not Covered

581 4 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERE Not Covered NC NC NC NC Not Covered

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

661 2 COAGULATION/PLATELET DISORDER Med LV PD PD 2.9 PER DIEM

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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 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, 2016

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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

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

950 3 EXTENSIVE PROC UNREL PDX Surg 1.3164 28,080.88 1,460.21 13.9 APR-DRG

L&I uses APR-DRG Version 31 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, 2016

APR-DRG

NumberSOI APR-DRG Description

DRG

Type

Relative

Weight

High Outlier

Threshold

Low Outlier

Threshold

Avg

LOS

Paid

Using

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 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 37