All Acute Care and Psychiatric Providers, and Rehabilitation Hospitals

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1 Indiana Health Coverage Programs P R O V I D E R B U L L E T I N B T S E P T E M B E R 1 6, To: All Acute Care and Psychiatric Providers, and Rehabilitation Hospitals Subject: Changes in Diagnosis-Related Group Relative s and New Long-Term Acute Care Hospital Level-of-Care Reimbursement Methodology Overview In accordance with Indiana Code (IC) IC , this bulletin notifies providers of new diagnosis-related group (DRG) relative weights, outlier threshold, and long-term acute care (LTAC) hospital level-of-care methodology for reimbursement for Indiana Health Coverage Programs (IHCP) inpatient hospital services. New weights are effective for services with admissions made on or after November 1, LTAC rates are also effective on November 1, LTAC hospitals will be reimbursed under the level-of-care reimbursement methodology. Other than as noted in this bulletin, billing procedures for inpatient hospital services have not changed. Please refer to the IHCP Provider Manual and IHCP provider bulletins for specific billing instructions. Grouper Effective for dates of admission on or after November 1, 2003, the IHCP will discontinue use of the AP DRG Grouper, Version 14.1, and will begin using the AP DRG Grouper, Version 18. For information about purchasing the AP DRG Grouper software, contact Peggy Rambicure, RHIA, at ext or (859) For technical assistance, contact 3M technical support by telephone at or by at healthcare@mmm.com. Further information is available on the 3M Health Information Systems Web site at Relative s DRG relative weights and average lengths of stay were updated to reflect changes in relative cost and treatment patterns. A complete list of new relative weights and average lengths of stay () are listed in Table 1.3. The new relative weights and average lengths of stay are effective for dates of admission on or after November 1, EDS Page 1 of 22

2 DRG Outlier Payments The IHCP defines a DRG outlier case as a Medicaid stay with costs that exceed a predetermined threshold. Day outliers, Medicaid days that exceed a predetermined threshold, are not reimbursed under the DRG outlier payment policy. To determine outlier payment amounts, costs per Medicaid stay are calculated by multiplying a hospital-specific, cost-to-charge ratio by allowed charges. The payment is then a percentage of the difference between the cost per stay and the outlier threshold. Effective November 1, 2003, the outlier threshold is the greater of twice the DRG amount (base rate multiplied by the relative weight) or $34,425. The marginal cost percentage remains at 60 percent. At this time, providers global cost-to-charge ratios used to calculate DRG outlier payments have not been adjusted. New DRG Codes The following DRGs are new and valid with the Version 18 Grouper: Table 1.1 New DRG for Version 18 Grouper DRG Description 810 Intracranial hemorrhage 811 Cardiac defibrillator and heart assist system implant 812 Malfunction, reaction & comp of cardiac or vasc device or proc 813 Nonbacterial gastroenteritis & abdominal pain age > 17 w cc 814 Nonbacterial gastroenteritis & abdominal pain age > 17 w/o cc 815 Nonbacterial gastroenteritis & abdominal pain age < 18 w cc 816 Nonbacterial gastroenteritis & abdominal pain age < 18 w/o cc 817 Hip replacement for complications 818 Hip replacement except for complications 819 Create, revise or remove renal access device 820 Malfunctions, reactions & comp of gu device/graft/transplant 821 Extensive 3rd degree burns w skin graft 822 Extensive 3rd degree burns w/o skin graft 823 Full thickness burn w skin graft or inhal inj w cc or sig trauma 824 Full thickness burn w skin graft or inhal inj w/o cc or sig trauma 825 Full thickness burn w/o skin grft or inhal inj w cc or sig trauma 826 Full thickness burn w/o skin grft or inhal inj w/o cc or sig trauma 827 Non-extensive burns w inhal inj, cc or significant trauma 828 Non-extensive burns w/o inhal inj, cc or significant trauma New Long-Term Acute Care Hospital Level-of-Care Methodology The IHCP has amended 405 IAC to permit a separate level-of-care per diem, billing instructions, and billing frequency for LTAC hospitals. Information about level-of-care reimbursement methodology can be found in the IHCP Provider Manual, Chapter 7. EDS Page 2 of 22

3 An LTAC hospital is a freestanding general acute care hospital licensed under IC meeting the following criteria: 1. Is designated by the Medicare program as a long-term hospital; or 2. Has an average inpatient length of stay greater than 25 days, based on the same criteria used by the Medicare program to determine whether a hospital's average length of stay is greater than 25 days. Rule amendments were published in the February 2001 edition of the Indiana Register. The new per diem rates will become effective for dates of admission on or after November 1, Hospitals meeting the definition of an LTAC hospital are paid a daily rate, or per diem, for each day of care provided. The per diem is all-inclusive. No other payments are permitted in addition to the LTAC per diem. Qualifying providers were notified of the new LTAC rates. If a facility meets the definition of an LTAC hospital and has not been contacted, a representative of the facility should contact the Myers and Stauffer Hospital Unit at Qualifying providers must be enrolled as an LTAC hospital to receive the LTAC level-of-care per diem. For enrollment questions, please contact Provider Enrollment at Prior authorization (PA) is required for all LTAC admissions. Additional information about PA for these admissions will be communicated in a separate provider bulletin. To request PA for an LTAC admission, contact the HCE Prior Authorization Department at (317) in the Indianapolis local area or Resources Electronic resources are available to assist facilities in implementing the changes in this bulletin. Table 1.2 lists resources and sources. Table 1.2 Electronic Resources Electronic Resource Indiana Health Coverage Programs Provider Manual Indiana Health Coverage Programs provider bulletins Rate files in a spreadsheet format Source Additional Information Questions about the information in this bulletin should be directed to the Customer Assistance Unit at (317) in the Indianapolis local area or EDS Page 3 of 22

4 Table 1.3 DRG Relative Table 001 Craniotomy age >17 except for trauma Craniotomy for trauma age > Spinal procedures Extracranial vascular procedures Carpal tunnel release Periph & cranial nerve & other nerv syst proc w cc Periph & cranial nerve & other nerv syst proc w/o cc Spinal disorders & injuries Nervous system neoplasms w cc Nervous system neoplasms w/o cc Degenerative nervous system disorders Multiple sclerosis & cerebellar ataxia Specific cerebrovascular disorders except TIA Transient ischemic attack & precerebral occlusions Nonspecific cerebrovascular disorders w cc Nonspecific cerebrovascular disorders w/o cc Cranial & peripheral nerve disorders w cc Cranial & peripheral nerve disorders w/o cc Nervous system infection except viral meningitis Viral meningitis Hypertensive encephalopathy Nontraumatic stupor & coma Seizure & headache age >17 w cc Seizure & headache age >17 w/o cc Other disorders of nervous system w cc Other disorders of nervous system w/o cc Retinal procedures Orbital procedures Primary iris procedures Lens procedures with or without vitrectomy Extraocular procedures except orbit > Extraocular procedures except orbit < Intraocular except retina, iris & lens Hyphema Acute major eye infections Neurological eye disorders EDS Page 4 of 22

5 Table 1.3 DRG Relative Table 046 Other disorders of the eye age >17 w cc Other disorders of the eye age >17 w/o cc Other disorders of the eye age < Major head & neck procedures except for malignancy Sialoadenectomy Salivary gland procedures except sialoadenectomy Cleft lip & palate repair Sinus & mastoid procedures age > Sinus & mastoid procedures age < Miscellaneous ear, nose, mouth & throat procedures Rhinoplasty T&A proc, except tonsillectomy &/or adenoidect only, age > T&A proc, except tonsillectomy &/or adenoidect only, age < Tonsillectomy &/or adenoidectomy only, age > Tonsillectomy &/or adenoidectomy only, age < Myringotomy w tube insertion age > Myringotomy w tube insertion age < Other ear, nose, mouth & throat O.R. procedures Ear, nose, mouth & throat malignancy Dysequilibrium Epistaxis Epiglottitis Otitis media & uri age >17 w cc Otitis media & uri age >17 w/o cc Otitis media & uri age < Laryngotracheitis Nasal trauma & deformity Other ear, nose, mouth & throat diagnoses age > Other ear, nose, mouth & throat diagnoses age < Major chest procedures Other resp system O.R. procedures w cc Other resp system O.R. procedures w/o cc Pulmonary embolism Respiratory infections & inflammations age >17 w cc Respiratory infections & inflammations age >17 w/o cc Respiratory neoplasms EDS Page 5 of 22

6 Table 1.3 DRG Relative Table 083 Major chest trauma w cc Major chest trauma w/o cc Pleural effusion w cc Pleural effusion w/o cc Pulmonary edema & respiratory failure Chronic obstructive pulmonary disease Simple pneumonia & pleurisy age >17 w cc Simple pneumonia & pleurisy age >17 w/o cc Interstitial lung disease w cc Interstitial lung disease w/o cc Pneumothorax w cc Pneumothorax w/o cc Bronchitis & asthma age >17 w cc Bronchitis & asthma age >17 w/o cc Respiratory signs & symptoms w cc Respiratory signs & symptoms w/o cc Other respiratory system diagnoses w cc Other respiratory system diagnoses w/o cc Heart transplant Cardiac valve procedures w cardiac cath Cardiac valve procedures w/o cardiac cath Coronary bypass w cardiac cath Coronary bypass w/o cardiac cath Other cardiothoracic proc w/o pdx congenital anomaly Major cardiovascular procedures w cc Major cardiovascular procedures w/o cc Percutaneous cardiovascular proc w/o AMI, heart failure or shock Amputation for circ system disord except upper limb & toe Upper limb & toe amputation for circ system disorders Perm cardiac pacemaker impl w AMI, heart failure or shock Oth perm cardiac pacemaker implant or AICD lead or generator proc Cardiac pacemaker revision except device replacement Cardiac pacemaker device replacement Vein ligation & stripping Other circulatory system O.R. procedures Circulatory disorders w AMI & c.v. comp disch alive EDS Page 6 of 22

7 Table 1.3 DRG Relative Table 122 Circulatory disorders w/o AMI & c.v. comp disch alive Circulatory disorders w AMI, expired Circulatory disord except AMI, w card cath & complex diag Circulatory disord except AMI, w card cath w/o complex diag Acute & subacute endocarditis Heart failure & shock Deep vein thrombophlebitis Cardiac arrest, unexplained Peripheral vascular disorders w cc Peripheral vascular disorders w/o cc Atherosclerosis w cc Atherosclerosis w/o cc Hypertension Cardiac congenital & valvular disorders age >17 w cc Cardiac congenital & valvular disorders age >17 w/o cc Cardiac congenital & valvular disorders age < Cardiac arrhythmia & conduction disorders w cc Cardiac arrhythmia & conduction disorders w/o cc Angina pectoris Syncope & collapse w cc Syncope & collapse w/o cc Chest pain Other circulatory system diagnoses w cc Other circulatory system diagnoses w/o cc Rectal resection w cc Rectal resection w/o cc Major small & large bowel procedures w cc Major small & large bowel procedures w/o cc Peritoneal adhesiolysis w cc Peritoneal adhesiolysis w/o cc Minor small & large bowel procedures w cc Minor small & large bowel procedures w/o cc Stomach, esophageal & duodenal procedures age >17 w cc Stomach, esophageal & duodenal procedures age >17 w/o cc Stomach, esophageal & duodenal procedures age < Anal & stomal procedures w cc EDS Page 7 of 22

8 Table 1.3 DRG Relative Table 158 Anal & stomal procedures w/o cc Hernia procedures except inguinal & femoral age >17 w cc Hernia procedures except inguinal & femoral age >17 w/o cc Inguinal & femoral hernia procedures age >17 w cc Inguinal & femoral hernia procedures age >17 w/o cc Hernia procedures age < Appendectomy w complicated principal diag w cc Appendectomy w complicated principal diag w/o cc Appendectomy w/o complicated principal diag w cc Appendectomy w complicated principal diag w/o cc Mouth procedures w cc Mouth procedures w/o cc Other digestive system O.R. procedures w cc Other digestive system O.R. procedures w/o cc Digestive malignancy w cc Digestive malignancy w/o cc G.I. hemorrhage w cc G.I. hemorrhage w/o cc Complicated peptic ulcer Uncomplicated peptic ulcer w cc Uncomplicated peptic ulcer wo cc Inflammatory bowel disease G.I. obstruction w cc G.I. obstruction w/o cc Esophagitis, gastroent & misc digest disord age >17 w cc Esophagitis, gastroent & misc digest disord age >17 w cc Dental & oral dis except extractions & restorations, age > Dental & oral dis except extractions & restorations, age < Dental extractions & restorations Other digestive system diagnoses age >17 w cc Other digestive system diagnoses age >17 w/o cc Pancreas, liver & shunt procedures w cc Pancreas, liver & shunt procedures w/o cc Biliary tract proc except only cholecyst w or w/o c.d.e. w cc Biliary tract proc except only cholecyst w or w/o c.d.e. w/o cc Cholecystectomy w c.d.e. w cc EDS Page 8 of 22

9 Table 1.3 DRG Relative Table 196 Cholecystectomy w c.d.e. w/o cc Cholecystectomy w/o c.d.e. w cc Cholecystectomy w/o c.d.e. w/o cc Hepatobiliary diagnostic procedure for malignancy Hepatobiliary diagnostic procedure for non-malignancy Other hepatobiliary or pancreas O.R. procedures Cirrhosis & alcoholic hepatitis Malignancy of hepatobiliary system or pancreas Disorders or pancreas except malignancy Disorders of liver except malig, cirr, alc hepa w cc Disorders of liver except malig, cirr, alc hepa w/o cc Disorders of the biliary tract w cc Disorders of the biliary tract w/o cc Maj joint & limb reattach proc of low ext exc for complications Hip & femur procedures except major joint age >17 w cc Hip & femur procedures except major joint age >17 w/o cc Hip & femur procedures except major joint age < Amputation for musculoskelet system & conn tissue disorders Biopsies of musculoskeletal system & connective tissue Wnd debrid & skin grft exc opn wnd, for ms & conn tis dis, exc hand Lower extrem & humer proc exc hip, foot, femur age >17 w cc Lower extrem & humer proc exc hip, foot, femur age >17 w/o cc Lower extrem & humer proc exc hip, mfoot, femur age < Knee procedures w cc Knee procedures w/o cc Major shoulder/elbow proc, or oth upper extremity proc w cc Shoulder, elbow or forearm proc, exc major joint proc, w/o cc Foot procedures Soft tissue procedures w cc Soft tissue procedures w/o cc Major thumb or joint proc, or oth hand or wrist proc w cc Hand or wrist proc, except major joint proc, w/o cc Local excision & removal of int fix devices of hip & femur Local excision & removal of int fix devices of exc hip & femur Arthroscopy Other musculoskelet sys & conn tiss O.R. proc w cc EDS Page 9 of 22

10 Table 1.3 DRG Relative Table 234 Other musculoskelet sys & conn tiss O.R. proc w/o cc Fractures of femur Fractures of hip & pelvis Sprains, strains, & dislocations of hip, pelvis & thigh Osteomyelitis Pathological fractures & musculoskelet & conn tiss malignancy Connective tissue disorders w cc Connective tissue disorders w/o cc Septic arthritis Medical back problems Bone diseases & specific arthropathies w cc Bone diseases & specific arthropathies w/o cc Non-specific arthropathies Signs & symptoms of musculoskeletal system & conn tissue Tendonitis, myositis & bursitis care, musculoskeletal system & connective tissue Fx, sprn, strn & disl of forearm, hand, foot age >17 w cc Fx, sprn, strn & disl of forearm, hand, foot age >17 w/o cc Fx, sprn, strn & disl of forearm, hand, foot age < Fx, sprn, strn & disl of uparm, lowleg ex, foot age >17 w cc Fx, sprn, strn & disl of uparm, lowleg ex, foot age >17 w/o cc Fx, sprn, strn & disl of uparm, lowleg ex, foot age < Other musculoskeletal system & connective tissue diagnoses Total mastectomy for malignancy w cc Total mastectomy for malignancy w/o cc Subtotal mastectomy for malignancy w cc Subtotal mastectomy for malignancy w/o cc Breast proc for non-malignancy except biopsy & local excision Breast biopsy & local excision for non-malignancy Skin graft &/or debrid for skn ulcer, cellulitis w cc Skin graft &/or debrid for skn ulcer, cellulitis w/o cc Skin graft &/or debrid exc for skn ulcer, cellulitis w cc Skin graft &/or debrid exc for skn ulcer, cellulitis w/o cc Perianal & pilonidal procedures Skin, subcutaneous tissue & breast plastic procedures Other skin, subcut tiss & breast proc w cc EDS Page 10 of 22

11 Table 1.3 DRG Relative Table 270 Other skin, subcut tiss & breast proc w/o cc Skin ulcers Major skin disorders w cc Major skin disorders w/o cc Malignant breast disorders w cc Malignant breast disorders w/o cc Non-malignant breast disorders Cellulitis age >17 w cc Cellulitis age >17 w/o cc Cellulitis age < Trauma to the skin, subcut tiss & breast age >17 w cc Trauma to the skin, subcut tiss & breast age >17 w/o cc Trauma to the skin, subcut tiss & breast age < Minor skin disorders w cc Minor skin disorders w/o cc Amputat of low limb for endocrine, nutrit, & metabol disorders Adrenal & pituitary procedures Skin graft & wound debrid for endoc, nutrit & metab disorders O.R. procedures for obesity Parathyroid procedures Thyroid procedures Thyroglossal procedures Other endocrine, nutrit & metab O.R. proc w cc Other endocrine, nutrit & metab O.R. proc w/o cc Diabetes age > Diabetes age < Nutritional & misc metabolic disorders age >17 w cc Nutritional & misc metabolic disorders age >17 w/o cc Nutritional & misc metabolic disorders age < Inborn errors of metabolism Endocrine disorders w cc Endocrine disorders w/o cc Kidney transplant Kidney, ureter & maj bladder proc for neoplasm Kidney, ureter & maj bladder proc for non-neoplasm w cc Kidney, ureter & maj bladder proc for non-neoplasm w/o cc EDS Page 11 of 22

12 Table 1.3 DRG Relative Table 306 Prostatectomy w cc Prostatectomy w/o cc Minor bladder procedures w cc Minor bladder procedures w/o cc Transurethral procedures w cc Transurethral procedures w/o cc Urethral procedures age >17 w cc Urethral procedures age >17 w/o cc Urethral procedures age < Other kidney & urinary tract O.R. procedures Renal failure Admit for renal dialysis Kidney & urinary tract neoplasms w cc Kidney & urinary tract neoplasms w/o cc Kidney & urinary tract neoplasms age >17 w cc Kidney & urinary tract neoplasms age >17 w/o cc Kidney & urinary tract neoplasms age < Urinary stones w cc &/or esw lithotripsy Urinary stones w/o cc Kidney & urinary tract signs & symptoms age >17 w cc Kidney & urinary tract signs & symptoms age >17 w/o cc Kidney & urinary tract signs & symptoms age < Urethral stricture age >17 w cc Urethral stricture age >17 w/o cc Urethral stricture age < Other kidney & urinary tract diagnoses age >17 w cc Other kidney & urinary tract diagnoses age >17 w/o cc Other kidney & urinary tract diagnoses age < Major male pelvic procedures w cc Major male pelvic procedures w/o cc Transurethral prostatectomy w cc Transurethral prostatectomy w/o cc Testes procedures, for malignancy Testes procedures, for malignancy age > Testes procedures, for malignancy age < Penis procedures EDS Page 12 of 22

13 Table 1.3 DRG Relative Table 342 Circumcision age > Circumcision age < Other male reproductive syst O.R. proc for malignancy Other male reproductive syst O.R. proc except for malignancy Malignancy, male reproductive system, w cc Malignancy, male reproductive system, w/o cc Benign prostatic hypertrophy w cc Benign prostatic hypertrophy w/o cc Inflammation of the male reproductive system Sterilization, male Other male reproductive system diagnoses Pelvic evisceration, radical hysterect & readical vulvectomy Uterine, adnexa proc for non-ovarian/adnexal malignancy w cc Uterine, adnexa proc for non-ovarian/adnexal malignancy w/o cc Female reproductive system reconstructive procedures Uterine, adnexa proc for ovarian or adnexal malignancy Uterine, adnexa proc for ca in situ & non-malignancy w cc Uterine, adnexa proc for ca in situ & non-malignancy w/o cc Vagina, cervix & vulva procedures Laparoscopy & incisional tubal interruption Endoscopic tubal interruption D&C, conization & radio-implant, for malignancy D&C, conization except for malignancy Other female reproductive system O.R. procedures Malignancy, female reproductive system, w cc Malignancy, female reproductive system, w/o cc Infections, female reproductive system Menstrual & other female reproductive system disorders Cesarean section w cc Cesarean section w/o cc Vaginal delivery w complicating diagnoses Vaginal delivery w/o complicating diagnoses Vaginal delivery w sterilization &/or D&C Vaginal delivery w O.R. proc except steril &/or D&C Postpartum & post abortion diagnoses w/o O.R. procedure Postpartum & post abortion diagnoses w O.R. procedure EDS Page 13 of 22

14 Table 1.3 DRG Relative Table 378 Ectopic pregnancy Threatened abortion Abortion w/o D&C Abortion w D&C, aspiration curettage or hysterotomy False labor Other antepartum diagnoses w medical complications Other antepartum diagnoses w/o medical complications Splenectomy age > Splenectomy age < Other O.R. procedures of blood and blood forming organs Red blood cell disorders age > Coagulation disorders Reticuloendothelial & immunity disorders w cc Reticuloendothelial & immunity disorders w/o cc Lymphoma & leukemia w major O.R. procedure Lymphoma & non-acute leukemia w major O.R. proc w cc Lymphoma & non-acute leukemia w major O.R. proc w/o cc Lymphoma & non-acute leukemia w cc Lymphoma & non-acute leukemia w/o cc Myeloprolif disord or poor diff neopl w maj O.R. proc w cc Myeloprolif disord or poor diff neopl w maj O.R. proc w/o cc Myeloprolif disord or poor diff neopl w other O.R. proc Radiotherapy Chemotherapy History of malignancy w/o endoscopy History of malignancy w endoscopy Other myeloprofic dis or poor diff neopl diag w cc Other myeloprofic dis or poor diff neopl diag w/o cc O.R. procedure for infectious & parasitic diseases Septicemia age > Septicemia age < Postoperative & post-traumatic infections Fever of unknown origin age >17 w cc Fever of unknown origin age >17 w/o cc Viral illness age > Viral illness & fever of unknown origin age < EDS Page 14 of 22

15 Table 1.3 DRG Relative Table 423 Other infectious & parasitic diseases diagnoses O.R. procedures w principal diagnoses of mental illness LOC LOC LOC LOC 425 Acute adjust react & disturbance or psychocsocial dysfunction LOC LOC LOC LOC 426 Depressive neuroses LOC LOC LOC LOC 427 Neuroses except depressive LOC LOC LOC LOC 428 Disorders of personality & impulse control LOC LOC LOC LOC 429 Organic disturbances & mental retardation (ICD-9 Diag ) Psychoses LOC LOC LOC LOC 431 Childhood mental disorders LOC LOC LOC LOC 432 Other mental disorder diagnoses LOC LOC LOC LOC 439 Skin grafts for injuries Wound debridements for injuries except open wounds Hand procedures for injuries Other O.R. procedures for injuries w cc Other O.R. procedures for injuries w/o cc Injuries to unspecified or multiple sites age >17 w cc Injuries to unspecified or multiple sites age >17 w/o cc Injuries to unspecified or multiple sites age < Allergic reactions age > Allergic reactions age < Poisoning & toxic effects of drugs age >17 w cc Poisoning & toxic effects of drugs age >17 w/o cc Poisoning & toxic effects of drugs age < Complication of treatment w cc Complication of treatment w/o cc Other injury, poisoning & toxic effect diagnosis w cc Other injury, poisoning & toxic effect diagnosis w/o cc Burns, transferred to another acute care facility LOC LOC LOC LOC 457 Extensive burns w/o O.R. procedure LOC LOC LOC LOC 458 Non-extensive burns w skin graft LOC LOC LOC LOC 459 Non-extensive burns w wound debridement or other O.R. proc LOC LOC LOC LOC 460 Non-extensive burns w/o O.R. procedure O.R. proc w diagnoses of other contact w health services Rehabilitation LOC LOC LOC LOC 463 Signs & symptoms w cc Signs & symptoms w/o cc EDS Page 15 of 22

16 Table 1.3 DRG Relative Table 465 care w history of malignancy as secondary diagnosis care w/o history of malignancy as secondary diagnosis Other factors influencing health status Extensive O.R. procedure unrelated to principal diagnosis Principal diagnosis invalid as discharge diagnosis Ungroupable Bilateral or multiple major joint procs of lower extremity Extensive burns w O.R. procedure LOC LOC LOC LOC 475 Respiratory system diagnosis with ventilator support Prostatic O.R. procedure unrelated to principal diagnosis Non-extensive O.R. procedure unrelated to principal diagnosis Other vascular procedures w cc Other vascular procedures w/o cc Liver transplant Tracheostomy for face, mouth & neck diagnoses Tracheostomy except for face, mouth & neck diagnoses Major joint & limb reattachment procedures of upper extremity Laparoscopic cholecystectomy w/o c.d.e. w cc Laparoscopic cholecystectomy w/o c.d.e. w/o cc Craniotomy w major cc Nervous system procedures except craniotomy w major cc TIA, precerebral occlusions, seizure & headache w major cc Other nervous system disord except TIA, seizure & headache w majo Eye procedures w major cc Eye disorders w major cc ENT & mouth procedures except major head & neck w major cc ENT & mouth disorders w major cc Major chest procedures w major cc Respiratory procedures except major chest w major cc Respiratory infections & inflammations w major cc Respiratory disord except infections, bronchitis, asthma w major Bronchitis & asthma w major cc Circ disorders except AMI, endocarditis, CHF & arrhythmia CHF & cardiac arrhythmia w major cc Cardiac valve procedure w major cc EDS Page 16 of 22

17 Table 1.3 DRG Relative Table 546 Coronary bypass w major cc Other cardiothoracic procedures w major cc Oth cardiac pacemaker implant/revision or AICD proc w major cc Major cardiovascular procedures w major cc Other vascular procedures w major cc Esophagitis, gastroenteritis and uncomplicated ulcers w major cc Digest syst disord except esoph, gastroent and uncompl ulcers w major cc 553 Digest systproc exc hernia and major stomach or bowel proc w major cc Hernia procedures w major cc Pancreas, liver and oth bil tract proc except liver transplnt w major cc Cholecystectomy and other hepatobiliary procedures w major cc Hepatobiliary and pancreas disorders w major cc Major musculoskelet procs except bilat or mult major joint w major cc Non-major musculoskeletal procedures w major cc Musculoskel disord exc osteo, septic arth and conn tissue dis w majo Osteomyelitis, septic arthritis and conn tissue disorder w major cc Major skin and breast disorders w major cc Other skin disorders w major cc Skin and breast procedures w major cc Endocrine, nutrit and metab proc except lower limb amputat w major cc 566 Endocrine, nutrit and metab disord exc eating disorder or CF w major cc 567 Kidney and urinary tract procedures except kidney transplant w major cc Renal failure w major cc Kidney and urinary tract disorders except renal failure w major cc Male reproductive disorders w major cc Male reproductive procedures w major cc Female reproductive disorders w major cc Non-radical female reproductive procedures w major cc Blood, blood forming organs and immunological disorders w major cc EDS Page 17 of 22

18 Table 1.3 DRG Relative Table 575 Blood, blood forming organs and immunology, procedures w maj cc Acute leukemia w major cc Myeloprolif disorders and poorly differentiated neoplasms w major cc Lymphoma and non-acute leukemia w major cc Procedures for lymphoma, leukemia, myeloprolif disorders w major cc Systemic infections an parasitic disord except septicemia w major Systemic infections and parasitic disorder procedures w major cc Injuries except multiple trauma w major cc Procedures for injuries except multiple trauma w major cc Septicemia w major cc Major stomach, esophageal, duodenal, small and large ENT and mount disorders age > 17 w major cc ENT and mount disorders age <18 w major cc Neonate, birthwt < 750g, discharged alive Neonate, birthwt < 750g, died Neonate, birthwt g, discharged alive Neonate, birthwt g, died Neonate, birthwt g w/signif or proc, discharged alive Neonate, birthwt g w/o signif or proc, discharged alive Neonate, birthwt g, died Neonate, birthwt g, w signif or proc, w mult major prob Neonate, birthwt g, w signif or proc, w/o mult major prob 611 Neonate, birthwt g, w/o signif or proc, w mult major prob Neonate, birthwt g, w/o signif or proc, w major prob Neonate, birthwt g, w/o signif or proc, w minor prob Neonate, birthwt g, w/o signif or proc, w other prob Neonate, birthwt g, w signif or proc, w mult major prob Neonate, birthwt g, w signif or proc, w/o mult major prob 617 Neonate, birthwt g, w/o signif or proc, w mult major prob Neonate, birthwt g, w/o signif or proc, w major prob Neonate, birthwt g, w/o signif or proc, w minor prob EDS Page 18 of 22

19 Table 1.3 DRG Relative Table 620 Neonate, bwt g, w/o signif or proc, w normal newborn diag Neonate, birthwt g, w/o signif or proc, w other prob Neonate, birthwt >2499g, w signif or proc, w mult major prob Neonate, birthwt >2499g, w signif or proc, w/o mult major pro Neonate, birthwt >2499g, w minor abdom procedure Neonate, birthwt >2499g, w/o signif or proc, w mult major prob Neonate, birthwt >2499g, w/o signif or proc, w major prob Neonate, birthwt >2499g, w/o signif or proc, w minor prob Neonate, bwt >2499g, w/o signif or proc, w normal newborn diag Neonate, birthwt >2499g, w/o signif or proc, w other prob Bronch Pulm Dysplas and oth chronic respiratory diseases arising in perinatal period Multiple, other and unspecified congenital anomalies, w cc Multiple, other and unspecified congenital anomalies, w/o cc Neonatal aftercare for weight gain Infant aftercare for weight gain, age >28 days <1 year Neonate, died w/in one day of birth, born here Neonate, died /in one day of birth, not born here Neonate, transferred <5 days old, born here Neonate, transferred <5 days old, not born here Neonate, birthweight >2499g, w extracorporeal membrane oxygenation (ECHMO) High risk cesarean section w cc High risk cesarean section w/o cc High risk vaginal delivery w sterilization and/or D&C Tracheostomy for HIV infection HIV w o.r procedure and ventilator or nutritional support HIV w o.r procedure w multiple major related infections HIV w o.r procedure w major related diagnosis HIV w o.r procedure w/o major related diagnosis HIV w multiple major related infections w TB HIV w multiple major related infections w/o TB HIV w ventilator or nutritional support HIV w major related diagnosis, discharge ama HIV w major related diag w mult major or signif diag w TB HIV w major related diag w mult major or signif diag w/o TB EDS Page 19 of 22

20 Table 1.3 DRG Relative Table 711 HIV w major related diag w/o mult major or signif diag w TB HIV w major related diag w/o mult major or signif diag w/o TB HIV w significant related diagnosis, discharged ama HIV w significant related diagnosis HIV w other related diagnosis HIV w/o other related diagnosis Craniotomy for multiple significant trauma Spine, hip, femur or limb proc for multiple significant trauma Other O.R. procedure for multiple significant trauma Head, chest and lower limb diagnoses of multiple significant trauma Other diagnosis of multiple significant trauma Ventricular shunt revision age < Craniotomy age <18 w cc Craniotomy age <18 w/o cc Cystic fibrosis Opioid abuse or dependence, left against medical advice Opioid abuse or dependence w cc Opioid abuse or dependence w/o cc Cocaine or other drug abuse or dependence, left against medical a Cocaine or other drug abuse or dependence w cc Cocaine or other drug abuse or dependence w/o cc Alcohol abuse or dependence, left against medical advice Alcohol abuse or dependence, w cc Alcohol abuse or dependence, w/o cc Lead poisoning Compulsive nutrition disorder rehabilitation Tertiary aftercare, age =>1 year Spinal fusion w cc Spinal fusion w/o cc Back and neck procedures except spinal fusion w cc Back and neck procedures except spinal fusion w/o cc Multiple channel cochlear implants Hemophilia factors VII and IX Traumatic stupor and coma, coma >1 hr Concussion, intracranial injury w coma <1 hr or no coma age < Traumatic stupor and coma, coma <1 hr age < EDS Page 20 of 22

21 Table 1.3 DRG Relative Table 764 Concussion, intracranial injury w coma <1 hr or no coma age >17 w/o cc 765 Concussion, intracranial injury w coma <1 hr or no coma age >17 w cc Traumatic stupor and coma, coma <1 hr age >17 w cc Traumatic stupor and coma, coma <1 hr age >17 w/o cc Seizure and headache age <18 w cc Seizure and headache age <18 w/occ Respiratory infections and inflammations age <18 w cc Respiratory infections and inflammations age <18 w/o cc Simple pneumonia and pleurisy age <18 w cc Simple pneumonia and pleurisy age <18 w/o cc Bronchitis and asthma age <18 w cc Bronchitis and asthma age <18 w/o cc Esophagitis, gastroent and misc digest disord age <18 w cc Esophagitis, gastroent and misc digest disord age <18 w/o cc Other digestive diagnoses age <18 w cc Other digestive diagnoses age <18 w/o cc Acute leukemia w/o major O.R. procedure age <18 w cc Acute leukemia w/o major O.R. procedure age <18 w/o cc Acute leukemia w/o major O.R. procedure age >17 w cc Acute leukemia w/o major O.R. procedure age >17 w/o cc Acquired hemolytic anemia or sickle cell crisis age < Other red blood cell disorders age < Major head and neck procedures for malignancy Laparoscopic cholecystectomy w c.d.e Maj joint and limb reattach proc of low ext for complications Would debris and skin grft for open wnd, ms and conn tiss dis, exc hand Wound debridements for open wound injuries Craniotomy for multiple sig trauma with non-traumatic major cc Proc for mul sig trauma exc craniotomy w non-traumatic major cc Diag for mul sig trauma exc craniotomy w non-traumatic major cc Lung transplant Lower extremity revascularization w cc Lower extremity revascularization w/o cc Tuberculosis w operating room procedures EDS Page 21 of 22