APR-DRG Assignment - lni.wa.gov · APR-DRG Assignment Effective July 1, 2018 APR-DRG Number SOI...
96
Facilities Fee Schedule APR-DRG Assignment Effective July 1, 2018 APR-DRG Assignment Effective for Dates of Service on or After July 1, 2018 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 APR-DRG Assignment - lni.wa.gov · APR-DRG Assignment Effective July 1, 2018 APR-DRG Number SOI...
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG Assignment
Effective for Dates of Service on or After
July 1, 2018
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, 2018
Column
Title
APR-DRG
Number
SOI
APR-DRG
Description
Severity of Illness
All Patient Refined Diagnosis Related Group Number
Column Description
Indicates DRG Type or coverage status.
Abbreviated APR-DRG description.
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
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
Column Values Value Definitions
APR-DRG ASSIGNMENT
FIELD KEY:
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
PaymentHigh
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.
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, 2018
Column
Title Column Description
Avg. LOS Expected length of stay for conditions falling within the APR-DRG.
The average length of stay for the APR-DRG.
On cases paid using the relative weight times the base
The highest cost necessary to qualify as a low outlier.
APR-DRG does not qualify for outlier payments
APR-DRG is not covered by L&I
Days
PD
NC
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)
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
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, 2018
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
001 1 LIVER TRANS &/OR INTEST TRANS Surg LV PD
001 2 LIVER TRANS &/OR INTEST TRANS Surg LV PD
001 3 LIVER TRANS &/OR INTEST TRANS Surg LV PD
001 4 LIVER TRANS &/OR INTEST TRANS Surg LV PD
002 1 HEART &/OR LUNG TRANSPLANT Surg LV PD
002 2 HEART &/OR LUNG TRANSPLANT Surg LV PD
002 3 HEART &/OR LUNG TRANSPLANT Surg LV PD
002 4 HEART &/OR LUNG TRANSPLANT Surg LV PD
003 1 BONE MARROW TRANSPLANT Surg LV PD
003 2 BONE MARROW TRANSPLANT Surg LV PD
003 3 BONE MARROW TRANSPLANT Surg LV PD
003 4 BONE MARROW TRANSPLANT Surg LV PD
004 1 TRACH W MV 96+ W EXTN PROC OR ECMO Surg 13.4716 241,088.08
004 2 TRACH W MV 96+ W EXTN PROC OR ECMO Surg 13.4716 241,088.08
004 3 TRACH W MV 96+ W EXTN PROC OR ECMO Surg 13.4716 241,088.08
004 4 TRACH W MV 96+ W EXTN PROC OR ECMO Surg 13.4716 241,088.08
005 1 TRACH W MV 96+ WO EXTN PROC Surg LV PD
005 2 TRACH W MV 96+ WO EXTN PROC Surg LV PD
005 3 TRACH W MV 96+ WO EXTN PROC Surg LV PD
005 4 TRACH W MV 96+ WO EXTN PROC Surg LV PD
006 1 PANCREAS TRANSPLANT Surg LV PD
006 2 PANCREAS TRANSPLANT Surg LV PD
006 3 PANCREAS TRANSPLANT Surg LV PD
006 4 PANCREAS TRANSPLANT Surg LV PD
020 1 CRANIOTOMY FOR TRAUMA Surg 5.8473 95,067.41
020 2 CRANIOTOMY FOR TRAUMA Surg 5.8473 95,067.41
020 3 CRANIOTOMY FOR TRAUMA Surg 5.8473 95,067.41
020 4 CRANIOTOMY FOR TRAUMA Surg 5.8473 95,067.41
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
021 1 CRANIOTOMY EXC FOR TRAUMA Surg 1.5499 32,044.61
021 2 CRANIOTOMY EXC FOR TRAUMA Surg 2.7761 43,153.04
021 3 CRANIOTOMY EXC FOR TRAUMA Surg 5.8473 95,067.41
021 4 CRANIOTOMY EXC FOR TRAUMA Surg LV PD
022 1 VENTRICULAR SHUNT PROC Surg LV PD
022 2 VENTRICULAR SHUNT PROC Surg LV PD
022 3 VENTRICULAR SHUNT PROC Surg LV PD
022 4 VENTRICULAR SHUNT PROC Surg LV PD
023 1 SPINAL PROCEDURES Surg 3.4641 48,529.04
023 2 SPINAL PROCEDURES Surg 3.4641 48,529.04
023 3 SPINAL PROCEDURES Surg 3.4641 48,529.04
023 4 SPINAL PROCEDURES Surg 3.4641 48,529.04
024 1 EXTRACRANIAL VASCULAR PROC Surg LV PD
024 2 EXTRACRANIAL VASCULAR PROC Surg LV PD
024 3 EXTRACRANIAL VASCULAR PROC Surg LV PD
024 4 EXTRACRANIAL VASCULAR PROC Surg LV PD
026 1 OTH NERVOUS SYST & RELAT PROC Surg LV PD
026 2 OTH NERVOUS SYST & RELAT PROC Surg 1.3088 30,041.03
026 3 OTH NERVOUS SYST & RELAT PROC Surg 1.4023 31,122.52
026 4 OTH NERVOUS SYST & RELAT PROC Surg 1.4023 31,122.52
040 1 SPINAL DISORDERS & INJURIES Med 0.7360 17,726.58
040 2 SPINAL DISORDERS & INJURIES Med 0.7360 17,726.58
040 3 SPINAL DISORDERS & INJURIES Med 0.7360 17,726.58
040 4 SPINAL DISORDERS & INJURIES Med 0.7360 17,726.58
041 1 NERVOUS SYSTEM MALIGNANCY Med LV PD
041 2 NERVOUS SYSTEM MALIGNANCY Med LV PD
041 3 NERVOUS SYSTEM MALIGNANCY Med LV PD
041 4 NERVOUS SYSTEM MALIGNANCY Med LV PD
042 1 DEGENERATV NERV SYS DIS EXC MS Med LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
042 2 DEGENERATV NERV SYS DIS EXC MS Med LV PD
042 3 DEGENERATV NERV SYS DIS EXC MS Med LV PD
042 4 DEGENERATV NERV SYS DIS EXC MS Med LV PD
043 1 MULT SCLEROSIS/OTH DEMYELIN DX Med LV PD
043 2 MULT SCLEROSIS/OTH DEMYELIN DX Med LV PD
043 3 MULT SCLEROSIS/OTH DEMYELIN DX Med LV PD
043 4 MULT SCLEROSIS/OTH DEMYELIN DX Med LV PD
044 1 INTRACRANIAL HEMORRHAGE Med LV PD
044 2 INTRACRANIAL HEMORRHAGE Med LV PD
044 3 INTRACRANIAL HEMORRHAGE Med LV PD
044 4 INTRACRANIAL HEMORRHAGE Med LV PD
045 1 CVA W INFARCT Med LV PD
045 2 CVA W INFARCT Med LV PD
045 3 CVA W INFARCT Med LV PD
045 4 CVA W INFARCT Med LV PD
046 1 NONSPEC CVA & PRECEREB OCCL Med LV PD
046 2 NONSPEC CVA & PRECEREB OCCL Med LV PD
046 3 NONSPEC CVA & PRECEREB OCCL Med LV PD
046 4 NONSPEC CVA & PRECEREB OCCL Med LV PD
047 1 TRANSIENT ISCHEMIA Med LV PD
047 2 TRANSIENT ISCHEMIA Med LV PD
047 3 TRANSIENT ISCHEMIA Med LV PD
047 4 TRANSIENT ISCHEMIA Med LV PD
048 1 PERIPH CRANIAL AUTON NERV DX Med 0.5791 17,726.58
048 2 PERIPH CRANIAL AUTON NERV DX Med 0.5791 17,726.58
048 3 PERIPH CRANIAL AUTON NERV DX Med 0.7026 17,726.58
048 4 PERIPH CRANIAL AUTON NERV DX Med 0.7026 17,726.58
049 1 BACT & TUBERCULOUS NERV INFECT Med LV PD
049 2 BACT & TUBERCULOUS NERV INFECT Med LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
049 3 BACT & TUBERCULOUS NERV INFECT Med LV PD
049 4 BACT & TUBERCULOUS NERV INFECT Med LV PD
050 1 NON-BACT NERV INFECT EXC VM Med LV PD
050 2 NON-BACT NERV INFECT EXC VM Med LV PD
050 3 NON-BACT NERV INFECT EXC VM Med LV PD
050 4 NON-BACT NERV INFECT EXC VM Med LV PD
051 1 VIRAL MENINGITIS Med LV PD
051 2 VIRAL MENINGITIS Med LV PD
051 3 VIRAL MENINGITIS Med LV PD
051 4 VIRAL MENINGITIS Med LV PD
052 1 NONTRAUMA STUPOR & COMA Med LV PD
052 2 NONTRAUMA STUPOR & COMA Med LV PD
052 3 NONTRAUMA STUPOR & COMA Med LV PD
052 4 NONTRAUMA STUPOR & COMA Med LV PD
053 1 SEIZURE Med 0.5431 17,726.58
053 2 SEIZURE Med 0.5431 17,726.58
053 3 SEIZURE Med 0.5491 17,726.58
053 4 SEIZURE Med 0.5491 17,726.58
054 1 MIGRAINE & OTHER HEADACHE Med LV PD
054 2 MIGRAINE & OTHER HEADACHE Med LV PD
054 3 MIGRAINE & OTHER HEADACHE Med LV PD
054 4 MIGRAINE & OTHER HEADACHE Med LV PD
055 1 HEAD TRAUMA W COMA >1 HR/HEMOR Med 1.1473 17,726.58
055 2 HEAD TRAUMA W COMA >1 HR/HEMOR Med 1.1473 17,726.58
055 3 HEAD TRAUMA W COMA >1 HR/HEMOR Med 1.1473 17,726.58
055 4 HEAD TRAUMA W COMA >1 HR/HEMOR Med 1.1473 17,726.58
056 1 BRAIN CONTUSION/LACERATION Med 0.5678 17,726.58
056 2 BRAIN CONTUSION/LACERATION Med 0.5689 17,726.58
056 3 BRAIN CONTUSION/LACERATION Med 0.6555 17,726.58
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
056 4 BRAIN CONTUSION/LACERATION Med 0.7171 17,726.58
057 1 CONCUSSION/CLOSED SKULL FRACT Med LV PD
057 2 CONCUSSION/CLOSED SKULL FRACT Med LV PD
057 3 CONCUSSION/CLOSED SKULL FRACT Med LV PD
057 4 CONCUSSION/CLOSED SKULL FRACT Med LV PD
058 1 OTH DISORDERS NERVOUS SYS Med 0.6502 17,726.58
058 2 OTH DISORDERS NERVOUS SYS Med LV PD
058 3 OTH DISORDERS NERVOUS SYS Med LV PD
058 4 OTH DISORDERS NERVOUS SYS Med 2.2419 24,142.16
070 1 ORBITAL PROCEDURES Surg 1.2647 17,726.58
070 2 ORBITAL PROCEDURES Surg 1.2647 17,726.58
070 3 ORBITAL PROCEDURES Surg 1.2647 17,726.58
070 4 ORBITAL PROCEDURES Surg 1.2647 17,726.58
073 1 EYE PROCEDURES EXCEPT ORBIT Surg 0.6769 17,726.58
073 2 EYE PROCEDURES EXCEPT ORBIT Surg LV PD
073 3 EYE PROCEDURES EXCEPT ORBIT Surg LV PD
073 4 EYE PROCEDURES EXCEPT ORBIT Surg LV PD
080 1 ACUTE MAJOR EYE INFECTIONS Med LV PD
080 2 ACUTE MAJOR EYE INFECTIONS Med LV PD
080 3 ACUTE MAJOR EYE INFECTIONS Med LV PD
080 4 ACUTE MAJOR EYE INFECTIONS Med LV PD
082 1 EYE DISORDERS EXC MAJOR INFECT Med LV PD
082 2 EYE DISORDERS EXC MAJOR INFECT Med LV PD
082 3 EYE DISORDERS EXC MAJOR INFECT Med LV PD
082 4 EYE DISORDERS EXC MAJOR INFECT Med LV PD
089 1 MAJ CRANIAL/FACIAL BONE PROC Surg LV PD
089 2 MAJ CRANIAL/FACIAL BONE PROC Surg LV PD
089 3 MAJ CRANIAL/FACIAL BONE PROC Surg LV PD
089 4 MAJ CRANIAL/FACIAL BONE PROC Surg LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
090 1 MAJ LARYNX & TRACHEA PROC Surg LV PD
090 2 MAJ LARYNX & TRACHEA PROC Surg LV PD
090 3 MAJ LARYNX & TRACHEA PROC Surg LV PD
090 4 MAJ LARYNX & TRACHEA PROC Surg LV PD
091 1 OTH MAJ HEAD & NECK PROC Surg LV PD
091 2 OTH MAJ HEAD & NECK PROC Surg LV PD
091 3 OTH MAJ HEAD & NECK PROC Surg LV PD
091 4 OTH MAJ HEAD & NECK PROC Surg LV PD
092 1 FACIAL BONE PROC EXC MAJOR Surg LV PD
092 2 FACIAL BONE PROC EXC MAJOR Surg LV PD
092 3 FACIAL BONE PROC EXC MAJOR Surg LV PD
092 4 FACIAL BONE PROC EXC MAJOR Surg LV PD
093 1 SINUS & MASTOID PROC Surg LV PD
093 2 SINUS & MASTOID PROC Surg LV PD
093 3 SINUS & MASTOID PROC Surg LV PD
093 4 SINUS & MASTOID PROC Surg LV PD
095 1 CLEFT LIP & PALATE REPAIR Surg LV PD
095 2 CLEFT LIP & PALATE REPAIR Surg LV PD
095 3 CLEFT LIP & PALATE REPAIR Surg LV PD
095 4 CLEFT LIP & PALATE REPAIR Surg LV PD
097 1 TONSIL & ADENOID PROC Surg LV PD
097 2 TONSIL & ADENOID PROC Surg LV PD
097 3 TONSIL & ADENOID PROC Surg LV PD
097 4 TONSIL & ADENOID PROC Surg LV PD
098 1 OTH EAR NOSE MOUTH THROAT PROC Surg 0.8829 17,726.58
098 2 OTH EAR NOSE MOUTH THROAT PROC Surg LV PD
098 3 OTH EAR NOSE MOUTH THROAT PROC Surg LV PD
098 4 OTH EAR NOSE MOUTH THROAT PROC Surg LV PD
110 1 EAR NOSE MOUTH THROAT MALIG Med LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 10
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
110 2 EAR NOSE MOUTH THROAT MALIG Med LV PD
110 3 EAR NOSE MOUTH THROAT MALIG Med LV PD
110 4 EAR NOSE MOUTH THROAT MALIG Med LV PD
111 1 VERTIGO & OTHER LABYRINTH DX Med LV PD
111 2 VERTIGO & OTHER LABYRINTH DX Med LV PD
111 3 VERTIGO & OTHER LABYRINTH DX Med LV PD
111 4 VERTIGO & OTHER LABYRINTH DX Med LV PD
113 1 INFECTIONS OF UP RESP TRACT Med LV PD
113 2 INFECTIONS OF UP RESP TRACT Med LV PD
113 3 INFECTIONS OF UP RESP TRACT Med LV PD
113 4 INFECTIONS OF UP RESP TRACT Med LV PD
114 1 DENTAL & ORAL DISEASE & INJURY Med LV PD
114 2 DENTAL & ORAL DISEASE & INJURY Med LV PD
114 3 DENTAL & ORAL DISEASE & INJURY Med 4.6167 49,220.91
114 4 DENTAL & ORAL DISEASE & INJURY Med 4.6167 49,220.91
115 1 OTH EAR NOSE MOUTH THROAT CRAN DX Med LV PD
115 2 OTH EAR NOSE MOUTH THROAT CRAN DX Med LV PD
115 3 OTH EAR NOSE MOUTH THROAT CRAN DX Med LV PD
115 4 OTH EAR NOSE MOUTH THROAT CRAN DX Med LV PD
120 1 MAJ RESPIRATORY & CHEST PROC Surg LV PD
120 2 MAJ RESPIRATORY & CHEST PROC Surg LV PD
120 3 MAJ RESPIRATORY & CHEST PROC Surg 1.9783 20,449.22
120 4 MAJ RESPIRATORY & CHEST PROC Surg 1.9783 20,449.22
121 1 OTH RESPIRATORY & CHEST PROC Surg LV PD
121 2 OTH RESPIRATORY & CHEST PROC Surg LV PD
121 3 OTH RESPIRATORY & CHEST PROC Surg LV PD
121 4 OTH RESPIRATORY & CHEST PROC Surg LV PD
130 1 RESPIRATORY DX W MV 96+ HRS Med 1.2376 30,044.85
130 2 RESPIRATORY DX W MV 96+ HRS Med 1.2376 30,044.85
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 11
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
130 3 RESPIRATORY DX W MV 96+ HRS Med LV PD
130 4 RESPIRATORY DX W MV 96+ HRS Med LV PD
131 1 CYSTIC FIBROSIS-PULM DX Med LV PD
131 2 CYSTIC FIBROSIS-PULM DX Med LV PD
131 3 CYSTIC FIBROSIS-PULM DX Med LV PD
131 4 CYSTIC FIBROSIS-PULM DX Med LV PD
132 1 BPD & OTH CHRONIC RESP DIS Med LV PD
132 2 BPD & OTH CHRONIC RESP DIS Med LV PD
132 3 BPD & OTH CHRONIC RESP DIS Med LV PD
132 4 BPD & OTH CHRONIC RESP DIS Med LV PD
133 1 PULMONARY EDEMA & RESP FAIL Med 0.4320 17,726.58
133 2 PULMONARY EDEMA & RESP FAIL Med 0.5963 17,726.58
133 3 PULMONARY EDEMA & RESP FAIL Med 0.7271 17,726.58
133 4 PULMONARY EDEMA & RESP FAIL Med LV PD
134 1 PULMONARY EMBOLISM Med 0.6400 17,726.58
134 2 PULMONARY EMBOLISM Med 0.6400 17,726.58
134 3 PULMONARY EMBOLISM Med 0.6400 17,726.58
134 4 PULMONARY EMBOLISM Med 0.6400 17,726.58
135 1 MAJOR CHEST & RESP TRAUMA Med 0.5775 17,726.58
135 2 MAJOR CHEST & RESP TRAUMA Med 0.5775 17,726.58
135 3 MAJOR CHEST & RESP TRAUMA Med 0.6341 17,726.58
135 4 MAJOR CHEST & RESP TRAUMA Med 0.6341 17,726.58
136 1 RESPIRATORY MALIGNANCY Med 0.9353 17,726.58
136 2 RESPIRATORY MALIGNANCY Med 0.9353 17,726.58
136 3 RESPIRATORY MALIGNANCY Med 0.9356 17,726.58
136 4 RESPIRATORY MALIGNANCY Med 0.9353 17,726.58
137 1 MAJOR RESPIRATORY INFECTIONS Med LV PD
137 2 MAJOR RESPIRATORY INFECTIONS Med LV PD
137 3 MAJOR RESPIRATORY INFECTIONS Med 1.0077 17,726.58
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 12
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
137 4 MAJOR RESPIRATORY INFECTIONS Med 1.0077 17,726.58
138 1 BRONCHIOLITIS & RSV PNEUM Med LV PD
138 2 BRONCHIOLITIS & RSV PNEUM Med LV PD
138 3 BRONCHIOLITIS & RSV PNEUM Med LV PD
138 4 BRONCHIOLITIS & RSV PNEUM Med LV PD
139 1 OTHER PNEUMONIA Med 0.5469 17,726.58
139 2 OTHER PNEUMONIA Med 0.5469 17,726.58
139 3 OTHER PNEUMONIA Med 0.5838 17,726.58
139 4 OTHER PNEUMONIA Med 0.5838 17,726.58
140 1 CHRONIC OBSTRUCTIVE PULM DIS Med 0.5205 17,726.58
140 2 CHRONIC OBSTRUCTIVE PULM DIS Med 0.5205 17,726.58
140 3 CHRONIC OBSTRUCTIVE PULM DIS Med 0.5205 17,726.58
140 4 CHRONIC OBSTRUCTIVE PULM DIS Med 0.5205 17,726.58
141 1 ASTHMA Med 0.3875 17,726.58
141 2 ASTHMA Med 0.3875 17,726.58
141 3 ASTHMA Med LV PD
141 4 ASTHMA Med LV PD
142 1 INTERSTITIAL & ALVEOLAR LUNG DISEAS Med LV PD
142 2 INTERSTITIAL & ALVEOLAR LUNG DISEAS Med LV PD
142 3 INTERSTITIAL & ALVEOLAR LUNG DISEAS Med LV PD
142 4 INTERSTITIAL & ALVEOLAR LUNG DISEAS Med LV PD
143 1 OTH RESP DX EXC SIGN/SYM/MINOR Med 0.4688 17,726.58
143 2 OTH RESP DX EXC SIGN/SYM/MINOR Med 0.5488 17,726.58
143 3 OTH RESP DX EXC SIGN/SYM/MINOR Med LV PD
143 4 OTH RESP DX EXC SIGN/SYM/MINOR Med LV PD
144 1 RESP SIGNS/SYMPTOMS/MINOR DX Med LV PD
144 2 RESP SIGNS/SYMPTOMS/MINOR DX Med LV PD
144 3 RESP SIGNS/SYMPTOMS/MINOR DX Med LV PD
144 4 RESP SIGNS/SYMPTOMS/MINOR DX Med LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 13
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
160 1 MAJ CARDIOTHOR REPR HEART ANOM Surg LV PD
160 2 MAJ CARDIOTHOR REPR HEART ANOM Surg LV PD
160 3 MAJ CARDIOTHOR REPR HEART ANOM Surg LV PD
160 4 MAJ CARDIOTHOR REPR HEART ANOM Surg LV PD
161 1 CARD DEFIB/HEART ASST IMPLANT Surg LV PD
161 2 CARD DEFIB/HEART ASST IMPLANT Surg LV PD
161 3 CARD DEFIB/HEART ASST IMPLANT Surg LV PD
161 4 CARD DEFIB/HEART ASST IMPLANT Surg LV PD
162 1 CARDIAC VALVE PROC W/CATH Surg LV PD
162 2 CARDIAC VALVE PROC W/CATH Surg LV PD
162 3 CARDIAC VALVE PROC W/CATH Surg LV PD
162 4 CARDIAC VALVE PROC W/CATH Surg LV PD
163 1 CARDIAC VALVE PROC WO CATH Surg LV PD
163 2 CARDIAC VALVE PROC WO CATH Surg LV PD
163 3 CARDIAC VALVE PROC WO CATH Surg LV PD
163 4 CARDIAC VALVE PROC WO CATH Surg LV PD
165 1 CORONARY BYPASS W CATH/PERCUT Surg LV PD
165 2 CORONARY BYPASS W CATH/PERCUT Surg LV PD
165 3 CORONARY BYPASS W CATH/PERCUT Surg LV PD
165 4 CORONARY BYPASS W CATH/PERCUT Surg LV PD
166 1 CORONARY BYPASS WO CATH/PERCUT Surg LV PD
166 2 CORONARY BYPASS WO CATH/PERCUT Surg LV PD
166 3 CORONARY BYPASS WO CATH/PERCUT Surg LV PD
166 4 CORONARY BYPASS WO CATH/PERCUT Surg LV PD
167 1 OTHER CARDIOTHORACIC PROC Surg LV PD
167 2 OTHER CARDIOTHORACIC PROC Surg LV PD
167 3 OTHER CARDIOTHORACIC PROC Surg LV PD
167 4 OTHER CARDIOTHORACIC PROC Surg LV PD
169 1 MAJ THORAC&ABDOM VASCULAR PROC Surg LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 14
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
169 2 MAJ THORAC&ABDOM VASCULAR PROC Surg LV PD
169 3 MAJ THORAC&ABDOM VASCULAR PROC Surg LV PD
169 4 MAJ THORAC&ABDOM VASCULAR PROC Surg LV PD
170 1 PERM CARD PACEMAK W AMI/HF/SHK Surg LV PD
170 2 PERM CARD PACEMAK W AMI/HF/SHK Surg LV PD
170 3 PERM CARD PACEMAK W AMI/HF/SHK Surg LV PD
170 4 PERM CARD PACEMAK W AMI/HF/SHK Surg LV PD
171 1 PERM CARD PACEMK WO AMI/HF/SHK Surg LV PD
171 2 PERM CARD PACEMK WO AMI/HF/SHK Surg LV PD
171 3 PERM CARD PACEMK WO AMI/HF/SHK Surg LV PD
171 4 PERM CARD PACEMK WO AMI/HF/SHK Surg LV PD
173 1 OTHER VASCULAR PROCEDURES Surg 1.0784 19,996.24
173 2 OTHER VASCULAR PROCEDURES Surg 1.0784 19,996.24
173 3 OTHER VASCULAR PROCEDURES Surg 2.7763 41,202.06
173 4 OTHER VASCULAR PROCEDURES Surg LV PD
174 1 PERCUT CARDIOVASC PROC W/AMI Surg LV PD
174 2 PERCUT CARDIOVASC PROC W/AMI Surg LV PD
174 3 PERCUT CARDIOVASC PROC W/AMI Surg LV PD
174 4 PERCUT CARDIOVASC PROC W/AMI Surg LV PD
175 1 PERCUT CARDIOVASC WO AMI Surg LV PD
175 2 PERCUT CARDIOVASC WO AMI Surg LV PD
175 3 PERCUT CARDIOVASC WO AMI Surg LV PD
175 4 PERCUT CARDIOVASC WO AMI Surg LV PD
176 1 CARD PACEMAK & DEFIB REPL Surg LV PD
176 2 CARD PACEMAK & DEFIB REPL Surg LV PD
176 3 CARD PACEMAK & DEFIB REPL Surg LV PD
176 4 CARD PACEMAK & DEFIB REPL Surg LV PD
177 1 CARD PACEMAK & DEFIB REVIS Surg LV PD
177 2 CARD PACEMAK & DEFIB REVIS Surg LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
177 3 CARD PACEMAK & DEFIB REVIS Surg LV PD
177 4 CARD PACEMAK & DEFIB REVIS Surg LV PD
180 1 OTHER CIRCULATORY SYSTEM PROC Surg LV PD
180 2 OTHER CIRCULATORY SYSTEM PROC Surg LV PD
180 3 OTHER CIRCULATORY SYSTEM PROC Surg LV PD
180 4 OTHER CIRCULATORY SYSTEM PROC Surg LV PD
190 1 ACUTE MYOCARDIAL INFARCT Med LV PD
190 2 ACUTE MYOCARDIAL INFARCT Med LV PD
190 3 ACUTE MYOCARDIAL INFARCT Med LV PD
190 4 ACUTE MYOCARDIAL INFARCT Med LV PD
191 1 CARD CATHET EXC ISCHEMIA Med LV PD
191 2 CARD CATHET EXC ISCHEMIA Med LV PD
191 3 CARD CATHET EXC ISCHEMIA Med LV PD
191 4 CARD CATHET EXC ISCHEMIA Med LV PD
192 1 CARD CATHET W/ISCHEMIA Med LV PD
192 2 CARD CATHET W/ISCHEMIA Med LV PD
192 3 CARD CATHET W/ISCHEMIA Med LV PD
192 4 CARD CATHET W/ISCHEMIA Med LV PD
193 1 ACUTE & SUBACUTE ENDOCARDITIS Med LV PD
193 2 ACUTE & SUBACUTE ENDOCARDITIS Med LV PD
193 3 ACUTE & SUBACUTE ENDOCARDITIS Med LV PD
193 4 ACUTE & SUBACUTE ENDOCARDITIS Med LV PD
194 1 HEART FAILURE Med LV PD
194 2 HEART FAILURE Med LV PD
194 3 HEART FAILURE Med LV PD
194 4 HEART FAILURE Med LV PD
196 1 CARDIAC ARREST Med LV PD
196 2 CARDIAC ARREST Med LV PD
196 3 CARDIAC ARREST Med LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
196 4 CARDIAC ARREST Med LV PD
197 1 PERIPHERAL & OTH VASC DIS Med 0.4271 17,726.58
197 2 PERIPHERAL & OTH VASC DIS Med 0.5304 17,726.58
197 3 PERIPHERAL & OTH VASC DIS Med 0.6873 17,726.58
197 4 PERIPHERAL & OTH VASC DIS Med LV PD
198 1 ANGINA PECT & CORONARY ATH Med LV PD
198 2 ANGINA PECT & CORONARY ATH Med LV PD
198 3 ANGINA PECT & CORONARY ATH Med LV PD
198 4 ANGINA PECT & CORONARY ATH Med LV PD
199 1 HYPERTENSION Med LV PD
199 2 HYPERTENSION Med LV PD
199 3 HYPERTENSION Med LV PD
199 4 HYPERTENSION Med LV PD
200 1 CARD STRUCT & VALVE DIS Med LV PD
200 2 CARD STRUCT & VALVE DIS Med LV PD
200 3 CARD STRUCT & VALVE DIS Med LV PD
200 4 CARD STRUCT & VALVE DIS Med LV PD
201 1 CARD ARRHYTHMIA & CONDUCTN DIS Med LV PD
201 2 CARD ARRHYTHMIA & CONDUCTN DIS Med LV PD
201 3 CARD ARRHYTHMIA & CONDUCTN DIS Med 0.4660 17,726.58
201 4 CARD ARRHYTHMIA & CONDUCTN DIS Med 0.4660 17,726.58
203 1 CHEST PAIN Med 0.4094 17,726.58
203 2 CHEST PAIN Med 0.4094 17,726.58
203 3 CHEST PAIN Med 0.4094 17,726.58
203 4 CHEST PAIN Med 0.4094 17,726.58
204 1 SYNCOPE & COLLAPSE Med LV PD
204 2 SYNCOPE & COLLAPSE Med LV PD
204 3 SYNCOPE & COLLAPSE Med 0.4697 17,726.58
204 4 SYNCOPE & COLLAPSE Med 0.4697 17,726.58
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 17
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
205 1 CARDIOMYOPATHY Med LV PD
205 2 CARDIOMYOPATHY Med LV PD
205 3 CARDIOMYOPATHY Med LV PD
205 4 CARDIOMYOPATHY Med LV PD
206 1 COMP CARDIAC/VASC DEV OR PROC Med LV PD
206 2 COMP CARDIAC/VASC DEV OR PROC Med LV PD
206 3 COMP CARDIAC/VASC DEV OR PROC Med LV PD
206 4 COMP CARDIAC/VASC DEV OR PROC Med LV PD
207 1 OTH CIRCULATORY SYSTEM DX Med LV PD
207 2 OTH CIRCULATORY SYSTEM DX Med LV PD
207 3 OTH CIRCULATORY SYSTEM DX Med LV PD
207 4 OTH CIRCULATORY SYSTEM DX Med LV PD
220 1 MAJ STOM ESOPH DUOD PROC Surg LV PD
220 2 MAJ STOM ESOPH DUOD PROC Surg 2.0093 40,965.06
220 3 MAJ STOM ESOPH DUOD PROC Surg LV PD
220 4 MAJ STOM ESOPH DUOD PROC Surg LV PD
221 1 MAJ SMALL & LARGE BOWEL PROC Surg 1.5186 17,726.58
221 2 MAJ SMALL & LARGE BOWEL PROC Surg 1.5186 17,726.58
221 3 MAJ SMALL & LARGE BOWEL PROC Surg LV PD
221 4 MAJ SMALL & LARGE BOWEL PROC Surg LV PD
222 1 OTH STOM, ESOPH, DUOD PROC Surg LV PD
222 2 OTH STOM, ESOPH, DUOD PROC Surg LV PD
222 3 OTH STOM, ESOPH, DUOD PROC Surg LV PD
222 4 OTH STOM, ESOPH, DUOD PROC Surg LV PD
223 1 OTH SMALL & LARGE BOWEL PROC Surg LV PD
223 2 OTH SMALL & LARGE BOWEL PROC Surg LV PD
223 3 OTH SMALL & LARGE BOWEL PROC Surg LV PD
223 4 OTH SMALL & LARGE BOWEL PROC Surg LV PD
224 1 PERITONEAL ADHESIOLYSIS Surg LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 18
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
224 2 PERITONEAL ADHESIOLYSIS Surg LV PD
224 3 PERITONEAL ADHESIOLYSIS Surg LV PD
224 4 PERITONEAL ADHESIOLYSIS Surg LV PD
225 1 APPENDECTOMY Surg LV PD
225 2 APPENDECTOMY Surg LV PD
225 3 APPENDECTOMY Surg LV PD
225 4 APPENDECTOMY Surg LV PD
226 1 ANAL PROCEDURES Surg LV PD
226 2 ANAL PROCEDURES Surg LV PD
226 3 ANAL PROCEDURES Surg LV PD
226 4 ANAL PROCEDURES Surg LV PD
227 1 HERNIA PROC EXC INGUIN/FEM/UMB Surg 0.6714 17,726.58
227 2 HERNIA PROC EXC INGUIN/FEM/UMB Surg 0.7893 17,726.58
227 3 HERNIA PROC EXC INGUIN/FEM/UMB Surg LV PD
227 4 HERNIA PROC EXC INGUIN/FEM/UMB Surg LV PD
228 1 ING FEM & UMBIL HERNIA PROC Surg 0.5651 17,726.58
228 2 ING FEM & UMBIL HERNIA PROC Surg 0.5651 17,726.58
228 3 ING FEM & UMBIL HERNIA PROC Surg LV PD
228 4 ING FEM & UMBIL HERNIA PROC Surg LV PD
229 1 OTH DIGEST SYS & ABDOM PROC Surg LV PD
229 2 OTH DIGEST SYS & ABDOM PROC Surg 1.3149 30,130.79
229 3 OTH DIGEST SYS & ABDOM PROC Surg LV PD
229 4 OTH DIGEST SYS & ABDOM PROC Surg LV PD
240 1 DIGESTIVE MALIGNANCY Med LV PD
240 2 DIGESTIVE MALIGNANCY Med LV PD
240 3 DIGESTIVE MALIGNANCY Med LV PD
240 4 DIGESTIVE MALIGNANCY Med LV PD
241 1 PEPTIC ULCER & GASTRITIS Med 0.6410 17,726.58
241 2 PEPTIC ULCER & GASTRITIS Med LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
241 3 PEPTIC ULCER & GASTRITIS Med 0.9718 17,726.58
241 4 PEPTIC ULCER & GASTRITIS Med LV PD
242 1 MAJOR ESOPHAGEAL DISORDER Med LV PD
242 2 MAJOR ESOPHAGEAL DISORDER Med LV PD
242 3 MAJOR ESOPHAGEAL DISORDER Med LV PD
242 4 MAJOR ESOPHAGEAL DISORDER Med LV PD
243 1 OTHER ESOPHAGEAL DISORDER Med LV PD
243 2 OTHER ESOPHAGEAL DISORDER Med LV PD
243 3 OTHER ESOPHAGEAL DISORDER Med LV PD
243 4 OTHER ESOPHAGEAL DISORDER Med LV PD
244 1 DIVERTICULITIS&DIVERTICULOSIS Med LV PD
244 2 DIVERTICULITIS&DIVERTICULOSIS Med LV PD
244 3 DIVERTICULITIS&DIVERTICULOSIS Med LV PD
244 4 DIVERTICULITIS&DIVERTICULOSIS Med LV PD
245 1 INFLAMMATORY BOWEL DISEASE Med LV PD
245 2 INFLAMMATORY BOWEL DISEASE Med LV PD
245 3 INFLAMMATORY BOWEL DISEASE Med LV PD
245 4 INFLAMMATORY BOWEL DISEASE Med LV PD
246 1 GI VASCULAR INSUFFICIENCY Med LV PD
246 2 GI VASCULAR INSUFFICIENCY Med LV PD
246 3 GI VASCULAR INSUFFICIENCY Med LV PD
246 4 GI VASCULAR INSUFFICIENCY Med LV PD
247 1 INTESTINAL OBSTRUCTION Med LV PD
247 2 INTESTINAL OBSTRUCTION Med LV PD
247 3 INTESTINAL OBSTRUCTION Med LV PD
247 4 INTESTINAL OBSTRUCTION Med LV PD
248 1 MAJOR GI & PERITONEAL INFECTN Med LV PD
248 2 MAJOR GI & PERITONEAL INFECTN Med LV PD
248 3 MAJOR GI & PERITONEAL INFECTN Med LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
248 4 MAJOR GI & PERITONEAL INFECTN Med LV PD
249 1 NON-BACTERIAL GASTROENTERITIS Med LV PD
249 2 NON-BACTERIAL GASTROENTERITIS Med LV PD
249 3 NON-BACTERIAL GASTROENTERITIS Med LV PD
249 4 NON-BACTERIAL GASTROENTERITIS Med LV PD
251 1 ABDOMINAL PAIN Med 0.4792 17,726.58
251 2 ABDOMINAL PAIN Med 0.5914 17,726.58
251 3 ABDOMINAL PAIN Med LV PD
251 4 ABDOMINAL PAIN Med LV PD
252 1 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDURE Med LV PD
252 2 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDURE Med LV PD
252 3 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDURE Med LV PD
252 4 MALFUNCTION, REACTION & COMPLICATION OF G.I. DEVICE OR PROCEDURE Med LV PD
253 1 OTH/UNSPEC GI HEMORRHAGE Med 0.5784 17,726.58
253 2 OTH/UNSPEC GI HEMORRHAGE Med 0.5784 17,726.58
253 3 OTH/UNSPEC GI HEMORRHAGE Med LV PD
253 4 OTH/UNSPEC GI HEMORRHAGE Med LV PD
254 1 OTH DIGESTIVE SYSTEM DX Med 0.4437 17,726.58
254 2 OTH DIGESTIVE SYSTEM DX Med 0.5622 17,726.58
254 3 OTH DIGESTIVE SYSTEM DX Med 0.6381 17,726.58
254 4 OTH DIGESTIVE SYSTEM DX Med LV PD
260 1 MAJ PANCREAS/LIVER/SHUNT PROC Surg LV PD
260 2 MAJ PANCREAS/LIVER/SHUNT PROC Surg LV PD
260 3 MAJ PANCREAS/LIVER/SHUNT PROC Surg LV PD
260 4 MAJ PANCREAS/LIVER/SHUNT PROC Surg LV PD
261 1 MAJOR BILIARY TRACT PROC Surg LV PD
261 2 MAJOR BILIARY TRACT PROC Surg LV PD
261 3 MAJOR BILIARY TRACT PROC Surg LV PD
261 4 MAJOR BILIARY TRACT PROC Surg LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 21
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
262 1 CHOLECYSTECTOMY EXC LAP Surg LV PD
262 2 CHOLECYSTECTOMY EXC LAP Surg LV PD
262 3 CHOLECYSTECTOMY EXC LAP Surg LV PD
262 4 CHOLECYSTECTOMY EXC LAP Surg LV PD
263 1 LAP CHOLECYSTECTOMY Surg LV PD
263 2 LAP CHOLECYSTECTOMY Surg LV PD
263 3 LAP CHOLECYSTECTOMY Surg LV PD
263 4 LAP CHOLECYSTECTOMY Surg LV PD
264 1 OTH HEPATOB/PANCREAS/ABDM PROC Surg LV PD
264 2 OTH HEPATOB/PANCREAS/ABDM PROC Surg LV PD
264 3 OTH HEPATOB/PANCREAS/ABDM PROC Surg LV PD
264 4 OTH HEPATOB/PANCREAS/ABDM PROC Surg LV PD
279 1 HEPATIC COMA/OTH MAJ LIV DIS Med LV PD
279 2 HEPATIC COMA/OTH MAJ LIV DIS Med LV PD
279 3 HEPATIC COMA/OTH MAJ LIV DIS Med LV PD
279 4 HEPATIC COMA/OTH MAJ LIV DIS Med LV PD
280 1 ALCOHOLIC LIVER DISEASE Med LV PD
280 2 ALCOHOLIC LIVER DISEASE Med LV PD
280 3 ALCOHOLIC LIVER DISEASE Med LV PD
280 4 ALCOHOLIC LIVER DISEASE Med LV PD
281 1 MALIGNCY-HEPATOBIL & PANCREAS Med LV PD
281 2 MALIGNCY-HEPATOBIL & PANCREAS Med LV PD
281 3 MALIGNCY-HEPATOBIL & PANCREAS Med LV PD
281 4 MALIGNCY-HEPATOBIL & PANCREAS Med LV PD
282 1 PANCREAS DISORD EXC MALIG Med LV PD
282 2 PANCREAS DISORD EXC MALIG Med LV PD
282 3 PANCREAS DISORD EXC MALIG Med LV PD
282 4 PANCREAS DISORD EXC MALIG Med LV PD
283 1 OTHER DISORDERS OF LIVER Med 0.4587 17,726.58
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
283 2 OTHER DISORDERS OF LIVER Med 0.4587 17,726.58
283 3 OTHER DISORDERS OF LIVER Med 0.7007 17,726.58
283 4 OTHER DISORDERS OF LIVER Med 0.7007 17,726.58
284 1 DIS GALLBLADDER & BILIARY TRCT Med LV PD
284 2 DIS GALLBLADDER & BILIARY TRCT Med LV PD
284 3 DIS GALLBLADDER & BILIARY TRCT Med LV PD
284 4 DIS GALLBLADDER & BILIARY TRCT Med LV PD
301 1 HIP JOINT REPLACEMENT Surg 1.4517 25,346.22
301 2 HIP JOINT REPLACEMENT Surg 1.4517 25,346.22
301 3 HIP JOINT REPLACEMENT Surg 1.4848 26,436.83
301 4 HIP JOINT REPLACEMENT Surg 1.4848 26,436.83
302 1 KNEE JOINT REPLACEMENT Surg 1.2695 19,730.67
302 2 KNEE JOINT REPLACEMENT Surg 1.2695 19,730.67
302 3 KNEE JOINT REPLACEMENT Surg 1.3226 26,093.55
302 4 KNEE JOINT REPLACEMENT Surg 1.3226 19,730.67
303 1 DORS/LUMB FUSION FOR CURV BACK Surg LV PD
303 2 DORS/LUMB FUSION FOR CURV BACK Surg LV PD
303 3 DORS/LUMB FUSION FOR CURV BACK Surg LV PD
303 4 DORS/LUMB FUSION FOR CURV BACK Surg LV PD
304 1 DORS/LUMB FUSION EXC CURV BACK Surg 2.3356 42,303.37
304 2 DORS/LUMB FUSION EXC CURV BACK Surg 2.3356 42,303.37
304 3 DORS/LUMB FUSION EXC CURV BACK Surg 2.5930 46,991.16
304 4 DORS/LUMB FUSION EXC CURV BACK Surg 2.5930 46,991.16
305 1 AMPUTATION LOWER LIMB EXC TOE Surg 0.9015 21,338.61
305 2 AMPUTATION LOWER LIMB EXC TOE Surg 0.9015 21,338.61
305 3 AMPUTATION LOWER LIMB EXC TOE Surg 0.9034 21,338.61
305 4 AMPUTATION LOWER LIMB EXC TOE Surg 0.9034 21,338.61
308 1 HIP/FEM PROC EXC JT REPL-TRAUM Surg 2.2080 27,033.03
308 2 HIP/FEM PROC EXC JT REPL-TRAUM Surg 2.2080 27,033.03
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
308 3 HIP/FEM PROC EXC JT REPL-TRAUM Surg 2.2080 27,033.03
308 4 HIP/FEM PROC EXC JT REPL-TRAUM Surg 2.2080 27,033.03
309 1 HIP/FEM PROC EXC JT RPL-NONTR Surg 0.6855 17,726.58
309 2 HIP/FEM PROC EXC JT RPL-NONTR Surg 0.9199 17,726.58
309 3 HIP/FEM PROC EXC JT RPL-NONTR Surg LV PD
309 4 HIP/FEM PROC EXC JT RPL-NONTR Surg LV PD
310 1 INTERVERTEBRAL DISC EXCISION Surg LV PD
310 2 INTERVERTEBRAL DISC EXCISION Surg LV PD
310 3 INTERVERTEBRAL DISC EXCISION Surg LV PD
310 4 INTERVERTEBRAL DISC EXCISION Surg LV PD
312 1 SKIN GRFT EXC HAND-MSCKL/CONN Surg 0.7797 17,726.58
312 2 SKIN GRFT EXC HAND-MSCKL/CONN Surg 0.7797 17,726.58
312 3 SKIN GRFT EXC HAND-MSCKL/CONN Surg 1.9056 28,146.36
312 4 SKIN GRFT EXC HAND-MSCKL/CONN Surg 1.9056 28,146.36
313 1 KNEE & LOWER LEG PROC EXC FOOT Surg 0.7915 17,726.58
313 2 KNEE & LOWER LEG PROC EXC FOOT Surg 0.8272 17,726.58
313 3 KNEE & LOWER LEG PROC EXC FOOT Surg 0.9621 17,726.58
313 4 KNEE & LOWER LEG PROC EXC FOOT Surg 1.1997 17,726.58
314 1 FOOT & TOE PROCEDURES Surg 0.7804 17,726.58
314 2 FOOT & TOE PROCEDURES Surg 0.7804 17,726.58
314 3 FOOT & TOE PROCEDURES Surg LV PD
314 4 FOOT & TOE PROCEDURES Surg LV PD
315 1 SHOULDER UPPER ARM FOREARM PROC Surg 0.7129 17,726.58
315 2 SHOULDER UPPER ARM FOREARM PROC Surg 0.7759 17,726.58
315 3 SHOULDER UPPER ARM FOREARM PROC Surg 0.7759 17,726.58
315 4 SHOULDER UPPER ARM FOREARM PROC Surg 1.2239 19,980.68
316 1 HAND & WRIST PROCEDURES Surg 0.6159 17,726.58
316 2 HAND & WRIST PROCEDURES Surg 0.6883 23,639.29
316 3 HAND & WRIST PROCEDURES Surg 0.7037 17,726.58
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
316 4 HAND & WRIST PROCEDURES Surg 0.7037 17,726.58
317 1 TENDON/MUSCLE/SOFT TISS PROC Surg 0.6790 17,726.58
317 2 TENDON/MUSCLE/SOFT TISS PROC Surg 0.6791 17,726.58
317 3 TENDON/MUSCLE/SOFT TISS PROC Surg 0.7394 17,726.58
317 4 TENDON/MUSCLE/SOFT TISS PROC Surg 0.7394 17,726.58
320 1 OTH MUSCULOSKELETAL PROC Surg 0.8478 17,726.58
320 2 OTH MUSCULOSKELETAL PROC Surg 1.9717 26,878.62
320 3 OTH MUSCULOSKELETAL PROC Surg 2.0162 34,707.95
320 4 OTH MUSCULOSKELETAL PROC Surg LV PD
321 1 CERV SPINAL FUS/OTH BACK&NK PR Surg 1.0274 17,726.58
321 2 CERV SPINAL FUS/OTH BACK&NK PR Surg 1.2819 22,361.51
321 3 CERV SPINAL FUS/OTH BACK&NK PR Surg 3.0943 54,411.91
321 4 CERV SPINAL FUS/OTH BACK&NK PR Surg 4.6704 90,827.53
340 1 FRACTURE OF FEMUR Med LV PD
340 2 FRACTURE OF FEMUR Med LV PD
340 3 FRACTURE OF FEMUR Med LV PD
340 4 FRACTURE OF FEMUR Med LV PD
341 1 FX PELVIS/HIP DISLOCATION Med 0.5010 17,726.58
341 2 FX PELVIS/HIP DISLOCATION Med 0.5010 17,726.58
341 3 FX PELVIS/HIP DISLOCATION Med 0.5010 17,726.58
341 4 FX PELVIS/HIP DISLOCATION Med 0.5010 17,726.58
342 1 FX&DISLOCAT EXC FEM/PELV/BACK Med 0.4493 17,726.58
342 2 FX&DISLOCAT EXC FEM/PELV/BACK Med LV PD
342 3 FX&DISLOCAT EXC FEM/PELV/BACK Med 0.5269 17,726.58
342 4 FX&DISLOCAT EXC FEM/PELV/BACK Med LV PD
343 1 MUSCULOSKEL MALIGN & PATHOL FX Surg 0.6309 17,726.58
343 2 MUSCULOSKEL MALIGN & PATHOL FX Surg 0.7686 17,726.58
343 3 MUSCULOSKEL MALIGN & PATHOL FX Surg 0.7700 17,726.58
343 4 MUSCULOSKEL MALIGN & PATHOL FX Surg 2.6603 26,624.23
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
344 1 BONE/JOINT/OTH MUSCSKEL INFECT Med 0.7210 17,726.58
344 2 BONE/JOINT/OTH MUSCSKEL INFECT Med 0.8244 17,726.58
344 3 BONE/JOINT/OTH MUSCSKEL INFECT Med 0.8244 17,726.58
344 4 BONE/JOINT/OTH MUSCSKEL INFECT Med 0.8244 17,726.58
346 1 CONNECTIVE TISSUE DISORDER Med 0.4193 17,726.58
346 2 CONNECTIVE TISSUE DISORDER Med 0.4654 17,726.58
346 3 CONNECTIVE TISSUE DISORDER Med 0.4687 17,726.58
346 4 CONNECTIVE TISSUE DISORDER Med LV PD
347 1 BACK & NECK DIS FRACT & INJ Med 0.5157 17,726.58
347 2 BACK & NECK DIS FRACT & INJ Med 0.5157 17,726.58
347 3 BACK & NECK DIS FRACT & INJ Med 0.5157 17,726.58
347 4 BACK & NECK DIS FRACT & INJ Med 0.5157 17,726.58
349 1 MALF/REACT/COMP ORTH DEV/PROC Med 0.4480 17,726.58
349 2 MALF/REACT/COMP ORTH DEV/PROC Med 0.4480 17,726.58
349 3 MALF/REACT/COMP ORTH DEV/PROC Med 0.4480 17,726.58
349 4 MALF/REACT/COMP ORTH DEV/PROC Med 0.4480 17,726.58
351 1 OTH MUSCULOSKL & CONN TISS DX Med 0.4067 17,726.58
351 2 OTH MUSCULOSKL & CONN TISS DX Med 0.4078 17,726.58
351 3 OTH MUSCULOSKL & CONN TISS DX Med 0.4904 17,726.58
351 4 OTH MUSCULOSKL & CONN TISS DX Med LV PD
361 1 SKIN GRAFT-SKIN & SUBCU DX Surg 0.6352 17,726.58
361 2 SKIN GRAFT-SKIN & SUBCU DX Surg 0.6665 17,726.58
361 3 SKIN GRAFT-SKIN & SUBCU DX Surg 0.7453 17,726.58
361 4 SKIN GRAFT-SKIN & SUBCU DX Surg 0.7528 17,726.58
362 1 MASTECTOMY PROCEDURES Surg LV PD
362 2 MASTECTOMY PROCEDURES Surg LV PD
362 3 MASTECTOMY PROCEDURES Surg LV PD
362 4 MASTECTOMY PROCEDURES Surg LV PD
363 1 BREAST PROC EXC MASTECTOMY Surg 1.0172 25,868.83
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
363 2 BREAST PROC EXC MASTECTOMY Surg LV PD
363 3 BREAST PROC EXC MASTECTOMY Surg LV PD
363 4 BREAST PROC EXC MASTECTOMY Surg LV PD
364 1 OTHER SKIN & SUBCUT PROC Surg 0.5924 17,726.58
364 2 OTHER SKIN & SUBCUT PROC Surg 1.0510 17,726.58
364 3 OTHER SKIN & SUBCUT PROC Surg 1.3624 17,726.58
364 4 OTHER SKIN & SUBCUT PROC Surg 2.0742 20,404.26
380 1 SKIN ULCERS Med 0.5644 17,726.58
380 2 SKIN ULCERS Med 0.5644 17,726.58
380 3 SKIN ULCERS Med 0.5644 17,726.58
380 4 SKIN ULCERS Med 0.5644 17,726.58
381 1 MAJOR SKIN DISORDERS Med LV PD
381 2 MAJOR SKIN DISORDERS Med 0.6540 17,726.58
381 3 MAJOR SKIN DISORDERS Med LV PD
381 4 MAJOR SKIN DISORDERS Med LV PD
382 1 MALIGNANT BREAST DISORDERS Med LV PD
382 2 MALIGNANT BREAST DISORDERS Med LV PD
382 3 MALIGNANT BREAST DISORDERS Med LV PD
382 4 MALIGNANT BREAST DISORDERS Med LV PD
383 1 CELLULITIS & OTH BACT SKIN INF Med 0.3832 17,726.58
383 2 CELLULITIS & OTH BACT SKIN INF Med 0.4988 17,726.58
383 3 CELLULITIS & OTH BACT SKIN INF Med LV PD
383 4 CELLULITIS & OTH BACT SKIN INF Med LV PD
384 1 CONTUSION/OPEN WND SKIN/OTH TR Med 0.4629 17,726.58
384 2 CONTUSION/OPEN WND SKIN/OTH TR Med 0.5570 17,726.58
384 3 CONTUSION/OPEN WND SKIN/OTH TR Med LV PD
384 4 CONTUSION/OPEN WND SKIN/OTH TR Med LV PD
385 1 OTH SKIN/SUBCUT/BREAST DIS Med LV PD
385 2 OTH SKIN/SUBCUT/BREAST DIS Med LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
385 3 OTH SKIN/SUBCUT/BREAST DIS Med LV PD
385 4 OTH SKIN/SUBCUT/BREAST DIS Med LV PD
401 1 PITUITARY & ADRENAL PROC Surg LV PD
401 2 PITUITARY & ADRENAL PROC Surg LV PD
401 3 PITUITARY & ADRENAL PROC Surg LV PD
401 4 PITUITARY & ADRENAL PROC Surg LV PD
403 1 PROCEDURES FOR OBESITY Surg LV PD
403 2 PROCEDURES FOR OBESITY Surg LV PD
403 3 PROCEDURES FOR OBESITY Surg LV PD
403 4 PROCEDURES FOR OBESITY Surg LV PD
404 1 THYROID/PARATHYRD/THYROGL PROC Surg LV PD
404 2 THYROID/PARATHYRD/THYROGL PROC Surg LV PD
404 3 THYROID/PARATHYRD/THYROGL PROC Surg LV PD
404 4 THYROID/PARATHYRD/THYROGL PROC Surg LV PD
405 1 OTH PROC-ENDOCR/NUTRIT/MET DX Surg LV PD
405 2 OTH PROC-ENDOCR/NUTRIT/MET DX Surg LV PD
405 3 OTH PROC-ENDOCR/NUTRIT/MET DX Surg LV PD
405 4 OTH PROC-ENDOCR/NUTRIT/MET DX Surg LV PD
420 1 DIABETES Med LV PD
420 2 DIABETES Med LV PD
420 3 DIABETES Med LV PD
420 4 DIABETES Med LV PD
421 1 MALNUT FAIL THRIVE OTH NUTR DX Med LV PD
421 2 MALNUT FAIL THRIVE OTH NUTR DX Med LV PD
421 3 MALNUT FAIL THRIVE OTH NUTR DX Med LV PD
421 4 MALNUT FAIL THRIVE OTH NUTR DX Med LV PD
422 1 HYPOVOLEM/RELAT ELECTROLYTE DX Med LV PD
422 2 HYPOVOLEM/RELAT ELECTROLYTE DX Med LV PD
422 3 HYPOVOLEM/RELAT ELECTROLYTE DX Med LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
422 4 HYPOVOLEM/RELAT ELECTROLYTE DX Med LV PD
423 1 INBORN ERRORS METABOLISM Med LV PD
423 2 INBORN ERRORS METABOLISM Med LV PD
423 3 INBORN ERRORS METABOLISM Med LV PD
423 4 INBORN ERRORS METABOLISM Med LV PD
424 1 OTH ENDOCRINE DISORDERS Med 0.6272 17,726.58
424 2 OTH ENDOCRINE DISORDERS Med LV PD
424 3 OTH ENDOCRINE DISORDERS Med LV PD
424 4 OTH ENDOCRINE DISORDERS Med LV PD
425 1 ELECTROLYTE DIS EXC HYPOVOL Med LV PD
425 2 ELECTROLYTE DIS EXC HYPOVOL Med LV PD
425 3 ELECTROLYTE DIS EXC HYPOVOL Med LV PD
425 4 ELECTROLYTE DIS EXC HYPOVOL Med LV PD
440 1 KIDNEY TRANSPLANT Surg LV PD
440 2 KIDNEY TRANSPLANT Surg LV PD
440 3 KIDNEY TRANSPLANT Surg LV PD
440 4 KIDNEY TRANSPLANT Surg LV PD
441 1 MAJOR BLADDER PROC Surg LV PD
441 2 MAJOR BLADDER PROC Surg LV PD
441 3 MAJOR BLADDER PROC Surg LV PD
441 4 MAJOR BLADDER PROC Surg LV PD
442 1 KIDNEY/URINARY TRCT PROC-MALIG Surg LV PD
442 2 KIDNEY/URINARY TRCT PROC-MALIG Surg LV PD
442 3 KIDNEY/URINARY TRCT PROC-MALIG Surg LV PD
442 4 KIDNEY/URINARY TRCT PROC-MALIG Surg LV PD
443 1 KIDNEY/URIN TRCT PROC-NONMALIG Surg LV PD
443 2 KIDNEY/URIN TRCT PROC-NONMALIG Surg LV PD
443 3 KIDNEY/URIN TRCT PROC-NONMALIG Surg LV PD
443 4 KIDNEY/URIN TRCT PROC-NONMALIG Surg LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
444 1 RENAL DIALY ACC DEV PROC ONLY Surg LV PD
444 2 RENAL DIALY ACC DEV PROC ONLY Surg LV PD
444 3 RENAL DIALY ACC DEV PROC ONLY Surg LV PD
444 4 RENAL DIALY ACC DEV PROC ONLY Surg LV PD
445 1 OTHER BLADDER PROC Surg LV PD
445 2 OTHER BLADDER PROC Surg LV PD
445 3 OTHER BLADDER PROC Surg LV PD
445 4 OTHER BLADDER PROC Surg LV PD
446 1 URETHRAL & TRANSURETH PROC Surg LV PD
446 2 URETHRAL & TRANSURETH PROC Surg LV PD
446 3 URETHRAL & TRANSURETH PROC Surg LV PD
446 4 URETHRAL & TRANSURETH PROC Surg LV PD
447 1 OTH KID/URIN TRACT & REL PROC Surg LV PD
447 2 OTH KID/URIN TRACT & REL PROC Surg LV PD
447 3 OTH KID/URIN TRACT & REL PROC Surg LV PD
447 4 OTH KID/URIN TRACT & REL PROC Surg LV PD
460 1 RENAL FAILURE Med LV PD
460 2 RENAL FAILURE Med LV PD
460 3 RENAL FAILURE Med LV PD
460 4 RENAL FAILURE Med LV PD
461 1 KIDNEY/URINARY TRACT MALIG Med LV PD
461 2 KIDNEY/URINARY TRACT MALIG Med LV PD
461 3 KIDNEY/URINARY TRACT MALIG Med 0.4964 17,726.58
461 4 KIDNEY/URINARY TRACT MALIG Med 0.4964 17,726.58
462 1 NEPHRITIS & NEPHROSIS Med LV PD
462 2 NEPHRITIS & NEPHROSIS Med LV PD
462 3 NEPHRITIS & NEPHROSIS Med LV PD
462 4 NEPHRITIS & NEPHROSIS Med LV PD
463 1 KIDNEY/URIN TRACT INFECT Med LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
463 2 KIDNEY/URIN TRACT INFECT Med LV PD
463 3 KIDNEY/URIN TRACT INFECT Med LV PD
463 4 KIDNEY/URIN TRACT INFECT Med LV PD
465 1 URIN STONES&ACQ UP URIN OBSTR Med LV PD
465 2 URIN STONES&ACQ UP URIN OBSTR Med LV PD
465 3 URIN STONES&ACQ UP URIN OBSTR Med LV PD
465 4 URIN STONES&ACQ UP URIN OBSTR Med LV PD
466 1 MALF/REAC/COMP GU DEVICE/PROC Surg 0.7380 17,726.58
466 2 MALF/REAC/COMP GU DEVICE/PROC Surg 0.7380 17,726.58
466 3 MALF/REAC/COMP GU DEVICE/PROC Surg 0.8532 17,726.58
466 4 MALF/REAC/COMP GU DEVICE/PROC Surg 0.8532 17,726.58
468 1 OTH KIDNEY/URINARY TRACT DX Med 0.6335 17,726.58
468 2 OTH KIDNEY/URINARY TRACT DX Med 0.6618 17,726.58
468 3 OTH KIDNEY/URINARY TRACT DX Med LV PD
468 4 OTH KIDNEY/URINARY TRACT DX Med LV PD
480 1 MAJOR MALE PELVIC PROC Surg LV PD
480 2 MAJOR MALE PELVIC PROC Surg LV PD
480 3 MAJOR MALE PELVIC PROC Surg LV PD
480 4 MAJOR MALE PELVIC PROC Surg LV PD
481 1 PENIS PROCEDURES Surg LV PD
481 2 PENIS PROCEDURES Surg LV PD
481 3 PENIS PROCEDURES Surg LV PD
481 4 PENIS PROCEDURES Surg LV PD
482 1 TRANSURETHRAL PROSTATECTOMY Surg LV PD
482 2 TRANSURETHRAL PROSTATECTOMY Surg LV PD
482 3 TRANSURETHRAL PROSTATECTOMY Surg LV PD
482 4 TRANSURETHRAL PROSTATECTOMY Surg LV PD
483 1 TESTES & SCROTAL PROC Surg LV PD
483 2 TESTES & SCROTAL PROC Surg LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
483 3 TESTES & SCROTAL PROC Surg 0.5969 17,726.58
483 4 TESTES & SCROTAL PROC Surg 0.5969 17,726.58
484 1 OTH MALE REPROD SYST/REL PROC Surg LV PD
484 2 OTH MALE REPROD SYST/REL PROC Surg LV PD
484 3 OTH MALE REPROD SYST/REL PROC Surg LV PD
484 4 OTH MALE REPROD SYST/REL PROC Surg LV PD
500 1 MALIGNANCY MALE REPROD SYS Med LV PD
500 2 MALIGNANCY MALE REPROD SYS Med LV PD
500 3 MALIGNANCY MALE REPROD SYS Med LV PD
500 4 MALIGNANCY MALE REPROD SYS Med LV PD
501 1 MALE REPROD SYS DX EXC MALIG Med LV PD
501 2 MALE REPROD SYS DX EXC MALIG Med LV PD
501 3 MALE REPROD SYS DX EXC MALIG Med LV PD
501 4 MALE REPROD SYS DX EXC MALIG Med LV PD
510 1 PELVIC EVISC/RAD HYSTERECTOMY Surg LV PD
510 2 PELVIC EVISC/RAD HYSTERECTOMY Surg LV PD
510 3 PELVIC EVISC/RAD HYSTERECTOMY Surg LV PD
510 4 PELVIC EVISC/RAD HYSTERECTOMY Surg LV PD
511 1 UTER/ADNEX PROC-OVAR/AD MAL Surg LV PD
511 2 UTER/ADNEX PROC-OVAR/AD MAL Surg LV PD
511 3 UTER/ADNEX PROC-OVAR/AD MAL Surg LV PD
511 4 UTER/ADNEX PROC-OVAR/AD MAL Surg LV PD
512 1 UTER/ADNEX PROC-NON-OV/AD MAL Surg LV PD
512 2 UTER/ADNEX PROC-NON-OV/AD MAL Surg LV PD
512 3 UTER/ADNEX PROC-NON-OV/AD MAL Surg LV PD
512 4 UTER/ADNEX PROC-NON-OV/AD MAL Surg LV PD
513 1 UTER/ADNX PROC-NONMAL EXC LEIO Surg LV PD
513 2 UTER/ADNX PROC-NONMAL EXC LEIO Surg LV PD
513 3 UTER/ADNX PROC-NONMAL EXC LEIO Surg LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
513 4 UTER/ADNX PROC-NONMAL EXC LEIO Surg LV PD
514 1 FEMALE REPROD RECONSTRUCT PROC Surg LV PD
514 2 FEMALE REPROD RECONSTRUCT PROC Surg LV PD
514 3 FEMALE REPROD RECONSTRUCT PROC Surg LV PD
514 4 FEMALE REPROD RECONSTRUCT PROC Surg LV PD
517 1 DILATION & CURET FOR NON-OB DX Surg LV PD
517 2 DILATION & CURET FOR NON-OB DX Surg LV PD
517 3 DILATION & CURET FOR NON-OB DX Surg LV PD
517 4 DILATION & CURET FOR NON-OB DX Surg LV PD
518 1 OTH FEMALE REPRO SYS&REL PROC Surg LV PD
518 2 OTH FEMALE REPRO SYS&REL PROC Surg LV PD
518 3 OTH FEMALE REPRO SYS&REL PROC Surg LV PD
518 4 OTH FEMALE REPRO SYS&REL PROC Surg LV PD
519 1 UTERINE/ADNEX PROC-LEIOMYOMA Med LV PD
519 2 UTERINE/ADNEX PROC-LEIOMYOMA Med LV PD
519 3 UTERINE/ADNEX PROC-LEIOMYOMA Med LV PD
519 4 UTERINE/ADNEX PROC-LEIOMYOMA Med LV PD
530 1 FEMALE REPRO SYST MALIG Med LV PD
530 2 FEMALE REPRO SYST MALIG Med LV PD
530 3 FEMALE REPRO SYST MALIG Med LV PD
530 4 FEMALE REPRO SYST MALIG Med LV PD
531 1 FEMALE REPRO SYST INFECTION Med LV PD
531 2 FEMALE REPRO SYST INFECTION Med LV PD
531 3 FEMALE REPRO SYST INFECTION Med LV PD
531 4 FEMALE REPRO SYST INFECTION Med LV PD
532 1 MENSTRUAL/OTH FEMALE REPROD DX Med LV PD
532 2 MENSTRUAL/OTH FEMALE REPROD DX Med LV PD
532 3 MENSTRUAL/OTH FEMALE REPROD DX Med LV PD
532 4 MENSTRUAL/OTH FEMALE REPROD DX Med LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
540 1 CESAREAN DELIVERY Surg LV PD
540 2 CESAREAN DELIVERY Surg LV PD
540 3 CESAREAN DELIVERY Surg LV PD
540 4 CESAREAN DELIVERY Surg LV PD
541 1 VAGINAL DELIVERY W STERIL/D&C Surg LV PD
541 2 VAGINAL DELIVERY W STERIL/D&C Surg LV PD
541 3 VAGINAL DELIVERY W STERIL/D&C Surg LV PD
541 4 VAGINAL DELIVERY W STERIL/D&C Surg LV PD
542 1 VAG DEL W CMP PROC EX STER/D&C Med LV PD
542 2 VAG DEL W CMP PROC EX STER/D&C Med LV PD
542 3 VAG DEL W CMP PROC EX STER/D&C Med LV PD
542 4 VAG DEL W CMP PROC EX STER/D&C Med LV PD
544 1 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSIS Med LV PD
544 2 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSIS Med LV PD
544 3 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSIS Med LV PD
544 4 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTERTRIC DIAGNOSIS Med LV PD
545 1 ECTOPIC PREGNANCY PROC Med LV PD
545 2 ECTOPIC PREGNANCY PROC Med LV PD
545 3 ECTOPIC PREGNANCY PROC Med LV PD
545 4 ECTOPIC PREGNANCY PROC Med LV PD
546 1 OTH O.R. PROC-OB DX EXC DELIV Surg LV PD
546 2 OTH O.R. PROC-OB DX EXC DELIV Surg LV PD
546 3 OTH O.R. PROC-OB DX EXC DELIV Surg LV PD
546 4 OTH O.R. PROC-OB DX EXC DELIV Surg LV PD
560 1 VAGINAL DELIVERY Surg LV PD
560 2 VAGINAL DELIVERY Surg LV PD
560 3 VAGINAL DELIVERY Surg LV PD
560 4 VAGINAL DELIVERY Surg LV PD
561 1 POSTPARTUM & POST ABORTION DX Surg LV PD
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
561 2 POSTPARTUM & POST ABORTION DX Surg LV PD
561 3 POSTPARTUM & POST ABORTION DX Surg LV PD
561 4 POSTPARTUM & POST ABORTION DX Surg LV PD
563 1 THREATENED ABORTION Med LV PD
563 2 THREATENED ABORTION Med LV PD
563 3 THREATENED ABORTION Med LV PD
563 4 THREATENED ABORTION Med LV PD
564 1 ABORT WO D&C Surg LV PD
564 2 ABORT WO D&C Surg LV PD
564 3 ABORT WO D&C Surg LV PD
564 4 ABORT WO D&C Surg LV PD
565 1 FALSE LABOR Med LV PD
565 2 FALSE LABOR Med LV PD
565 3 FALSE LABOR Med LV PD
565 4 FALSE LABOR Med LV PD
566 1 OTHER ANTEPARTUM DIAGNOSES Med LV PD
566 2 OTHER ANTEPARTUM DIAGNOSES Med LV PD
566 3 OTHER ANTEPARTUM DIAGNOSES Med LV PD
566 4 OTHER ANTEPARTUM DIAGNOSES Med LV PD
580 1 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE Not Covered NC NC
580 2 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE Not Covered NC NC
580 3 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE Not Covered NC NC
580 4 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE Not Covered NC NC
581 1 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERE Not Covered NC NC
581 2 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERE Not Covered NC NC
581 3 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERE Not Covered NC NC
581 4 NEONATE, TRANSFERRED <5 DAYS OLD, BORN HERE Not Covered NC NC
583 1 NEONATE WITH ECMO Not Covered NC NC
583 2 NEONATE WITH ECMO Not Covered NC NC
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
583 3 NEONATE WITH ECMO Not Covered NC NC
583 4 NEONATE WITH ECMO Not Covered NC NC
588 1 NEO BW <1500G W/MAJ PROC Not Covered NC NC
588 2 NEO BW <1500G W/MAJ PROC Not Covered NC NC
588 3 NEO BW <1500G W/MAJ PROC Not Covered NC NC
588 4 NEO BW <1500G W/MAJ PROC Not Covered NC NC
589 1 NEO BW <500G OR GA <24 WEEKS Not Covered NC NC
589 2 NEO BW <500G OR GA <24 WEEKS Not Covered NC NC
589 3 NEO BW <500G OR GA <24 WEEKS Not Covered NC NC
589 4 NEO BW <500G OR GA <24 WEEKS Not Covered NC NC
591 1 NEO BW 500-749G WO MAJ PROC Not Covered NC NC
591 2 NEO BW 500-749G WO MAJ PROC Not Covered NC NC
591 3 NEO BW 500-749G WO MAJ PROC Not Covered NC NC
591 4 NEO BW 500-749G WO MAJ PROC Not Covered NC NC
593 1 NEO BW 750-999G WO MAJ PROC Not Covered NC NC
593 2 NEO BW 750-999G WO MAJ PROC Not Covered NC NC
593 3 NEO BW 750-999G WO MAJ PROC Not Covered NC NC
593 4 NEO BW 750-999G WO MAJ PROC Not Covered NC NC
602 1 NEO BW 1000-1249G W RDS/MJ ANM Not Covered NC NC
602 2 NEO BW 1000-1249G W RDS/MJ ANM Not Covered NC NC
602 3 NEO BW 1000-1249G W RDS/MJ ANM Not Covered NC NC
602 4 NEO BW 1000-1249G W RDS/MJ ANM Not Covered NC NC
603 1 NEO BW 1000-1249G W/WO OTH SIG Not Covered NC NC
603 2 NEO BW 1000-1249G W/WO OTH SIG Not Covered NC NC
603 3 NEO BW 1000-1249G W/WO OTH SIG Not Covered NC NC
603 4 NEO BW 1000-1249G W/WO OTH SIG Not Covered NC NC
607 1 NEO BW 1250-1499G W RDS/MJ ANM Not Covered NC NC
607 2 NEO BW 1250-1499G W RDS/MJ ANM Not Covered NC NC
607 3 NEO BW 1250-1499G W RDS/MJ ANM Not Covered NC NC
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, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
607 4 NEO BW 1250-1499G W RDS/MJ ANM Not Covered NC NC
608 1 NEO BW 1250-1499G W/WO OTH SIG Not Covered NC NC
608 2 NEO BW 1250-1499G W/WO OTH SIG Not Covered NC NC
608 3 NEO BW 1250-1499G W/WO OTH SIG Not Covered NC NC
608 4 NEO BW 1250-1499G W/WO OTH SIG Not Covered NC NC
609 1 NEO BW 1500-2499G W/MAJ PROC Not Covered NC NC
609 2 NEO BW 1500-2499G W/MAJ PROC Not Covered NC NC
609 3 NEO BW 1500-2499G W/MAJ PROC Not Covered NC NC
609 4 NEO BW 1500-2499G W/MAJ PROC Not Covered NC NC
611 1 NEO BW 1500-1999G W/MAJ ANOM Not Covered NC NC
611 2 NEO BW 1500-1999G W/MAJ ANOM Not Covered NC NC
611 3 NEO BW 1500-1999G W/MAJ ANOM Not Covered NC NC
611 4 NEO BW 1500-1999G W/MAJ ANOM Not Covered NC NC
612 1 NEO BW 1500-1999G W RDS/MJ RES Not Covered NC NC
612 2 NEO BW 1500-1999G W RDS/MJ RES Not Covered NC NC
612 3 NEO BW 1500-1999G W RDS/MJ RES Not Covered NC NC
612 4 NEO BW 1500-1999G W RDS/MJ RES Not Covered NC NC
613 1 NEO BW 1500-1999G PERIN INFEC Not Covered NC NC
613 2 NEO BW 1500-1999G PERIN INFEC Not Covered NC NC
613 3 NEO BW 1500-1999G PERIN INFEC Not Covered NC NC
613 4 NEO BW 1500-1999G PERIN INFEC Not Covered NC NC
614 1 NEO BW 1500-1999G W/WO OTH SIG Not Covered NC NC
614 2 NEO BW 1500-1999G W/WO OTH SIG Not Covered NC NC
614 3 NEO BW 1500-1999G W/WO OTH SIG Not Covered NC NC
614 4 NEO BW 1500-1999G W/WO OTH SIG Not Covered NC NC
621 1 NEO BW 2000-2499G W/MAJ ANOM Not Covered NC NC
621 2 NEO BW 2000-2499G W/MAJ ANOM Not Covered NC NC
621 3 NEO BW 2000-2499G W/MAJ ANOM Not Covered NC NC
621 4 NEO BW 2000-2499G W/MAJ ANOM Not Covered NC NC
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 37
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
622 1 NEO BW 2000-2499G W RDS/MJ RES Not Covered NC NC
622 2 NEO BW 2000-2499G W RDS/MJ RES Not Covered NC NC
622 3 NEO BW 2000-2499G W RDS/MJ RES Not Covered NC NC
622 4 NEO BW 2000-2499G W RDS/MJ RES Not Covered NC NC
623 1 NEO BW 2000-2499G PERIN INFEC Not Covered NC NC
623 2 NEO BW 2000-2499G PERIN INFEC Not Covered NC NC
623 3 NEO BW 2000-2499G PERIN INFEC Not Covered NC NC
623 4 NEO BW 2000-2499G PERIN INFEC Not Covered NC NC
625 1 NEO BW 2000-2499G OTH SIG DX Not Covered NC NC
625 2 NEO BW 2000-2499G OTH SIG DX Not Covered NC NC
625 3 NEO BW 2000-2499G OTH SIG DX Not Covered NC NC
625 4 NEO BW 2000-2499G OTH SIG DX Not Covered NC NC
626 1 NEO BW 2000-2499G NNB/OTH PROB Not Covered NC NC
626 2 NEO BW 2000-2499G NNB/OTH PROB Not Covered NC NC
626 3 NEO BW 2000-2499G NNB/OTH PROB Not Covered NC NC
626 4 NEO BW 2000-2499G NNB/OTH PROB Not Covered NC NC
630 1 NEO BW >2499G MAJ CV PROC Not Covered NC NC
630 2 NEO BW >2499G MAJ CV PROC Not Covered NC NC
630 3 NEO BW >2499G MAJ CV PROC Not Covered NC NC
630 4 NEO BW >2499G MAJ CV PROC Not Covered NC NC
631 1 NEO BW >2499G OTH MAJ PROC Not Covered NC NC
631 2 NEO BW >2499G OTH MAJ PROC Not Covered NC NC
631 3 NEO BW >2499G OTH MAJ PROC Not Covered NC NC
631 4 NEO BW >2499G OTH MAJ PROC Not Covered NC NC
633 1 NEO BW >2499G W/MAJ ANOM Not Covered NC NC
633 2 NEO BW >2499G W/MAJ ANOM Not Covered NC NC
633 3 NEO BW >2499G W/MAJ ANOM Not Covered NC NC
633 4 NEO BW >2499G W/MAJ ANOM Not Covered NC NC
634 1 NEO BW >2499G W RDS/MAJ RESP Not Covered NC NC
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 38
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
634 2 NEO BW >2499G W RDS/MAJ RESP Not Covered NC NC
634 3 NEO BW >2499G W RDS/MAJ RESP Not Covered NC NC
634 4 NEO BW >2499G W RDS/MAJ RESP Not Covered NC NC
636 1 NEO BW >2499G PERIN INFECT Not Covered NC NC
636 2 NEO BW >2499G PERIN INFECT Not Covered NC NC
636 3 NEO BW >2499G PERIN INFECT Not Covered NC NC
636 4 NEO BW >2499G PERIN INFECT Not Covered NC NC
639 1 NEO BW >2499G OTH SIG COND Not Covered NC NC
639 2 NEO BW >2499G OTH SIG COND Not Covered NC NC
639 3 NEO BW >2499G OTH SIG COND Not Covered NC NC
639 4 NEO BW >2499G OTH SIG COND Not Covered NC NC
640 1 NEO BW >2499G NORM NB/OTH PROB Not Covered NC NC
640 2 NEO BW >2499G NORM NB/OTH PROB Not Covered NC NC
640 3 NEO BW >2499G NORM NB/OTH PROB Not Covered NC NC
640 4 NEO BW >2499G NORM NB/OTH PROB Not Covered NC NC
650 1 SPLENECTOMY Surg LV PD
650 2 SPLENECTOMY Surg LV PD
650 3 SPLENECTOMY Surg LV PD
650 4 SPLENECTOMY Surg LV PD
651 1 OTHER PROCEDURES OF BLOOD Surg LV PD
651 2 OTHER PROCEDURES OF BLOOD Surg LV PD
651 3 OTHER PROCEDURES OF BLOOD Surg 1.6918 17,726.58
651 4 OTHER PROCEDURES OF BLOOD Surg LV PD
660 1 MAJ HEMATOLOGIC/IMMUNOL DX Med LV PD
660 2 MAJ HEMATOLOGIC/IMMUNOL DX Med LV PD
660 3 MAJ HEMATOLOGIC/IMMUNOL DX Med LV PD
660 4 MAJ HEMATOLOGIC/IMMUNOL DX Med LV PD
661 1 COAGULATION/PLATELET DISORDER Med LV PD
661 2 COAGULATION/PLATELET DISORDER Med LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 39
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
661 3 COAGULATION/PLATELET DISORDER Med LV PD
661 4 COAGULATION/PLATELET DISORDER Med LV PD
662 1 SICKLE CELL ANEMIA CRISIS Med LV PD
662 2 SICKLE CELL ANEMIA CRISIS Med LV PD
662 3 SICKLE CELL ANEMIA CRISIS Med LV PD
662 4 SICKLE CELL ANEMIA CRISIS Med LV PD
663 1 OTHER ANEMIA/BLOOD DISORD Med 0.6319 17,726.58
663 2 OTHER ANEMIA/BLOOD DISORD Med 0.6319 17,726.58
663 3 OTHER ANEMIA/BLOOD DISORD Med LV PD
663 4 OTHER ANEMIA/BLOOD DISORD Med LV PD
680 1 MAJ PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD
680 2 MAJ PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD
680 3 MAJ PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD
680 4 MAJ PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD
681 1 OTH PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD
681 2 OTH PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD
681 3 OTH PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD
681 4 OTH PROC LYMPH/HEMAT/OTH NEOPL Surg LV PD
690 1 ACUTE LEUKEMIA Med LV PD
690 2 ACUTE LEUKEMIA Med LV PD
690 3 ACUTE LEUKEMIA Med LV PD
690 4 ACUTE LEUKEMIA Med LV PD
691 1 LYMPH/MYELO/NON-AC LEUK Med LV PD
691 2 LYMPH/MYELO/NON-AC LEUK Med LV PD
691 3 LYMPH/MYELO/NON-AC LEUK Med LV PD
691 4 LYMPH/MYELO/NON-AC LEUK Med LV PD
692 1 RADIOTHERAPY Med LV PD
692 2 RADIOTHERAPY Med LV PD
692 3 RADIOTHERAPY Med LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 40
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
692 4 RADIOTHERAPY Med LV PD
693 1 CHEMOTHERAPY Med LV PD
693 2 CHEMOTHERAPY Med LV PD
693 3 CHEMOTHERAPY Med LV PD
693 4 CHEMOTHERAPY Med LV PD
694 1 LYMPH & OTH MALIG & NEOPL Med LV PD
694 2 LYMPH & OTH MALIG & NEOPL Med LV PD
694 3 LYMPH & OTH MALIG & NEOPL Med LV PD
694 4 LYMPH & OTH MALIG & NEOPL Med LV PD
710 1 INFECT & PARASITIC DIS W PROC Surg 0.7960 17,726.58
710 2 INFECT & PARASITIC DIS W PROC Surg 0.7960 17,726.58
710 3 INFECT & PARASITIC DIS W PROC Surg 0.7960 17,726.58
710 4 INFECT & PARASITIC DIS W PROC Surg 0.7960 17,726.58
711 1 POSTOP/TRAUM/DEV INFECT W PROC Med 0.6287 17,726.58
711 2 POSTOP/TRAUM/DEV INFECT W PROC Med 0.6287 17,726.58
711 3 POSTOP/TRAUM/DEV INFECT W PROC Med LV PD
711 4 POSTOP/TRAUM/DEV INFECT W PROC Med LV PD
720 1 SEPTICEMIA & DISSEM INFECT Med 0.8260 17,726.58
720 2 SEPTICEMIA & DISSEM INFECT Med 0.8260 17,726.58
720 3 SEPTICEMIA & DISSEM INFECT Med 1.7452 17,726.58
720 4 SEPTICEMIA & DISSEM INFECT Med 1.7452 17,726.58
721 1 POST-OP/POST-TRAUM/DEV INFECT Med 0.4772 17,726.58
721 2 POST-OP/POST-TRAUM/DEV INFECT Med 0.4772 17,726.58
721 3 POST-OP/POST-TRAUM/DEV INFECT Med 0.4772 17,726.58
721 4 POST-OP/POST-TRAUM/DEV INFECT Med 0.4772 17,726.58
722 1 FEVER Med LV PD
722 2 FEVER Med LV PD
722 3 FEVER Med LV PD
722 4 FEVER Med LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 41
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
723 1 VIRAL ILLNESS Med LV PD
723 2 VIRAL ILLNESS Med LV PD
723 3 VIRAL ILLNESS Med LV PD
723 4 VIRAL ILLNESS Med LV PD
724 1 OTH INFECT & PARASITIC DIS Med 0.6917 17,726.58
724 2 OTH INFECT & PARASITIC DIS Med 0.6917 17,726.58
724 3 OTH INFECT & PARASITIC DIS Med 0.6996 17,726.58
724 4 OTH INFECT & PARASITIC DIS Med 0.6996 17,726.58
740 1 MENTAL ILLNESS DX W PROC Psych LV PD
740 2 MENTAL ILLNESS DX W PROC Psych LV PD
740 3 MENTAL ILLNESS DX W PROC Psych LV PD
740 4 MENTAL ILLNESS DX W PROC Psych LV PD
750 1 SCHIZOPHRENIA Psych LV PD
750 2 SCHIZOPHRENIA Psych LV PD
750 3 SCHIZOPHRENIA Psych LV PD
750 4 SCHIZOPHRENIA Psych LV PD
751 1 MAJOR DEPRESSIVE DISORDER Psych LV PD
751 2 MAJOR DEPRESSIVE DISORDER Psych LV PD
751 3 MAJOR DEPRESSIVE DISORDER Psych LV PD
751 4 MAJOR DEPRESSIVE DISORDER Psych LV PD
752 1 DIS PERSONALITY/IMPULSE CONTRL Psych LV PD
752 2 DIS PERSONALITY/IMPULSE CONTRL Psych LV PD
752 3 DIS PERSONALITY/IMPULSE CONTRL Psych LV PD
752 4 DIS PERSONALITY/IMPULSE CONTRL Psych LV PD
753 1 BIPOLAR DISORDERS Psych LV PD
753 2 BIPOLAR DISORDERS Psych LV PD
753 3 BIPOLAR DISORDERS Psych LV PD
753 4 BIPOLAR DISORDERS Psych LV PD
754 1 DEPRESSION EXC MAJ DEPRESSV DX Psych LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 42
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
754 2 DEPRESSION EXC MAJ DEPRESSV DX Psych LV PD
754 3 DEPRESSION EXC MAJ DEPRESSV DX Psych LV PD
754 4 DEPRESSION EXC MAJ DEPRESSV DX Psych LV PD
755 1 ADJUST DIS EXC DEPRESSIVE DX Psych LV PD
755 2 ADJUST DIS EXC DEPRESSIVE DX Psych LV PD
755 3 ADJUST DIS EXC DEPRESSIVE DX Psych LV PD
755 4 ADJUST DIS EXC DEPRESSIVE DX Psych LV PD
756 1 ACUTE ANXIETY & DELIRIUM Psych LV PD
756 2 ACUTE ANXIETY & DELIRIUM Psych LV PD
756 3 ACUTE ANXIETY & DELIRIUM Psych LV PD
756 4 ACUTE ANXIETY & DELIRIUM Psych LV PD
757 1 ORGANIC MENTAL HEALTH DIS Psych LV PD
757 2 ORGANIC MENTAL HEALTH DIS Psych LV PD
757 3 ORGANIC MENTAL HEALTH DIS Psych LV PD
757 4 ORGANIC MENTAL HEALTH DIS Psych LV PD
758 1 CHILDHOOD BEHAVIORAL DIS Not Covered NC NC
758 2 CHILDHOOD BEHAVIORAL DIS Not Covered NC NC
758 3 CHILDHOOD BEHAVIORAL DIS Not Covered NC NC
758 4 CHILDHOOD BEHAVIORAL DIS Not Covered NC NC
759 1 EATING DISORDERS Med LV PD
759 2 EATING DISORDERS Med LV PD
759 3 EATING DISORDERS Med LV PD
759 4 EATING DISORDERS Med LV PD
760 1 OTH MENTAL HEALTH DISORDER Psych LV PD
760 2 OTH MENTAL HEALTH DISORDER Psych LV PD
760 3 OTH MENTAL HEALTH DISORDER Psych LV PD
760 4 OTH MENTAL HEALTH DISORDER Psych LV PD
770 1 DRUG & ALCOHOL ABUSE - LAMA Chem LV PD
770 2 DRUG & ALCOHOL ABUSE - LAMA Chem LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 43
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
770 3 DRUG & ALCOHOL ABUSE - LAMA Chem LV PD
770 4 DRUG & ALCOHOL ABUSE - LAMA Chem LV PD
772 1 ALCOHOL/DRUG DEP W REHAB Chem LV PD
772 2 ALCOHOL/DRUG DEP W REHAB Chem LV PD
772 3 ALCOHOL/DRUG DEP W REHAB Chem LV PD
772 4 ALCOHOL/DRUG DEP W REHAB Chem LV PD
773 1 OPIOID ABUSE & DEPENDENCE Chem LV PD
773 2 OPIOID ABUSE & DEPENDENCE Chem LV PD
773 3 OPIOID ABUSE & DEPENDENCE Chem LV PD
773 4 OPIOID ABUSE & DEPENDENCE Chem LV PD
774 1 COCAINE ABUSE & DEPENDENCE Chem LV PD
774 2 COCAINE ABUSE & DEPENDENCE Chem LV PD
774 3 COCAINE ABUSE & DEPENDENCE Chem LV PD
774 4 COCAINE ABUSE & DEPENDENCE Chem LV PD
775 1 ALCOHOL ABUSE & DEPENDENCE Chem LV PD
775 2 ALCOHOL ABUSE & DEPENDENCE Chem LV PD
775 3 ALCOHOL ABUSE & DEPENDENCE Chem LV PD
775 4 ALCOHOL ABUSE & DEPENDENCE Chem LV PD
776 1 OTHER DRUG ABUSE & DEPEND Chem LV PD
776 2 OTHER DRUG ABUSE & DEPEND Chem LV PD
776 3 OTHER DRUG ABUSE & DEPEND Chem LV PD
776 4 OTHER DRUG ABUSE & DEPEND Chem LV PD
791 1 O.R. PROC OTH COMP TREAT Surg LV PD
791 2 O.R. PROC OTH COMP TREAT Surg LV PD
791 3 O.R. PROC OTH COMP TREAT Surg LV PD
791 4 O.R. PROC OTH COMP TREAT Surg LV PD
811 1 ALLERGIC REACTIONS Med LV PD
811 2 ALLERGIC REACTIONS Med LV PD
811 3 ALLERGIC REACTIONS Med LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 44
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
811 4 ALLERGIC REACTIONS Med LV PD
812 1 POISONING MEDICINAL AGENT Med 0.3381 17,726.58
812 2 POISONING MEDICINAL AGENT Med 0.3381 17,726.58
812 3 POISONING MEDICINAL AGENT Med 0.5728 17,726.58
812 4 POISONING MEDICINAL AGENT Med 0.5728 17,726.58
813 1 OTH COMP OF TREATMENT Surg 0.6277 17,726.58
813 2 OTH COMP OF TREATMENT Surg 0.6277 17,726.58
813 3 OTH COMP OF TREATMENT Surg 1.6460 17,726.58
813 4 OTH COMP OF TREATMENT Surg 1.6460 17,726.58
815 1 OTH INJ/ POISON/TOXIC DX Med 0.4338 17,726.58
815 2 OTH INJ/ POISON/TOXIC DX Med 0.4728 17,726.58
815 3 OTH INJ/ POISON/TOXIC DX Med 0.5541 17,726.58
815 4 OTH INJ/ POISON/TOXIC DX Med LV PD
816 1 TOXIC EFFECTS NON-MEDC SUBST Med LV PD
816 2 TOXIC EFFECTS NON-MEDC SUBST Med LV PD
816 3 TOXIC EFFECTS NON-MEDC SUBST Med LV PD
816 4 TOXIC EFFECTS NON-MEDC SUBST Med LV PD
841 1 EXTEN 3RD DEG BURN W GRAFT Surg LV PD
841 2 EXTEN 3RD DEG BURN W GRAFT Surg LV PD
841 3 EXTEN 3RD DEG BURN W GRAFT Surg LV PD
841 4 EXTEN 3RD DEG BURN W GRAFT Surg LV PD
842 1 FULL THICK BURNS W GRAFT Surg 1.2373 28,425.48
842 2 FULL THICK BURNS W GRAFT Surg 1.2373 28,425.48
842 3 FULL THICK BURNS W GRAFT Surg LV PD
842 4 FULL THICK BURNS W GRAFT Surg LV PD
843 1 EXT 3RD/FULL THCK BURN WO GRFT Med 0.4267 17,726.58
843 2 EXT 3RD/FULL THCK BURN WO GRFT Med LV PD
843 3 EXT 3RD/FULL THCK BURN WO GRFT Med LV PD
843 4 EXT 3RD/FULL THCK BURN WO GRFT Med LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 45
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
844 1 PART THICK BURNS W/WO GRAFT Med 0.3962 17,726.58
844 2 PART THICK BURNS W/WO GRAFT Med 0.3962 17,726.58
844 3 PART THICK BURNS W/WO GRAFT Med 0.5133 34,075.40
844 4 PART THICK BURNS W/WO GRAFT Med 0.5133 34,075.40
850 1 PROC W DX REHAB Rehab LV PD
850 2 PROC W DX REHAB Rehab LV PD
850 3 PROC W DX REHAB Rehab LV PD
850 4 PROC W DX REHAB Rehab LV PD
860 1 REHABILITATION Rehab LV PD
860 2 REHABILITATION Rehab LV PD
860 3 REHABILITATION Rehab LV PD
860 4 REHABILITATION Rehab LV PD
861 1 SIGNS/SYMPTOMS/OTH FACTORS Med 0.3891 17,726.58
861 2 SIGNS/SYMPTOMS/OTH FACTORS Med 0.7246 17,726.58
861 3 SIGNS/SYMPTOMS/OTH FACTORS Med LV PD
861 4 SIGNS/SYMPTOMS/OTH FACTORS Med LV PD
862 1 OTH AFTERCARE & CONVALES Med LV PD
862 2 OTH AFTERCARE & CONVALES Med LV PD
862 3 OTH AFTERCARE & CONVALES Med LV PD
862 4 OTH AFTERCARE & CONVALES Med LV PD
863 1 NEONATAL AFTERCARE Med LV PD
863 2 NEONATAL AFTERCARE Med LV PD
863 3 NEONATAL AFTERCARE Med LV PD
863 4 NEONATAL AFTERCARE Med LV PD
890 1 HIV W MULT MAJOR HIV REL CONDS Med LV PD
890 2 HIV W MULT MAJOR HIV REL CONDS Med LV PD
890 3 HIV W MULT MAJOR HIV REL CONDS Med LV PD
890 4 HIV W MULT MAJOR HIV REL CONDS Med LV PD
892 1 HIV W MAJOR HIV REL COND Surg LV PD
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 46
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
892 2 HIV W MAJOR HIV REL COND Surg LV PD
892 3 HIV W MAJOR HIV REL COND Surg LV PD
892 4 HIV W MAJOR HIV REL COND Surg LV PD
893 1 HIV W MULT SIGN HIV REL CONDS Med LV PD
893 2 HIV W MULT SIGN HIV REL CONDS Med LV PD
893 3 HIV W MULT SIGN HIV REL CONDS Med LV PD
893 4 HIV W MULT SIGN HIV REL CONDS Med LV PD
894 1 HIV W/WO ONE SIGNIF HIV COND Med LV PD
894 2 HIV W/WO ONE SIGNIF HIV COND Med LV PD
894 3 HIV W/WO ONE SIGNIF HIV COND Med LV PD
894 4 HIV W/WO ONE SIGNIF HIV COND Med LV PD
910 1 CRANIOTOMY MULT SIG TRAUMA Surg LV PD
910 2 CRANIOTOMY MULT SIG TRAUMA Surg LV PD
910 3 CRANIOTOMY MULT SIG TRAUMA Surg 6.0469 98,284.31
910 4 CRANIOTOMY MULT SIG TRAUMA Surg 6.0469 98,284.31
911 1 EXT ABD/THORAC PROC FOR MST Surg LV PD
911 2 EXT ABD/THORAC PROC FOR MST Surg LV PD
911 3 EXT ABD/THORAC PROC FOR MST Surg LV PD
911 4 EXT ABD/THORAC PROC FOR MST Surg LV PD
912 1 MUSCKL/OTH PROC MULT SIG TRAUM Surg 1.2744 18,377.32
912 2 MUSCKL/OTH PROC MULT SIG TRAUM Surg 1.9918 42,099.91
912 3 MUSCKL/OTH PROC MULT SIG TRAUM Surg 3.0113 29,190.09
912 4 MUSCKL/OTH PROC MULT SIG TRAUM Surg 3.8671 72,975.40
930 1 MULTIPLE SIG TRAUMA WO PROC Med 0.7479 17,726.58
930 2 MULTIPLE SIG TRAUMA WO PROC Med 0.7479 17,726.58
930 3 MULTIPLE SIG TRAUMA WO PROC Med 0.9181 17,726.58
930 4 MULTIPLE SIG TRAUMA WO PROC Med 3.8127 49,795.99
950 1 EXTENSIVE PROC UNREL PDX Surg 1.3164 28,080.88
950 2 EXTENSIVE PROC UNREL PDX Surg 1.3164 28,080.88
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 47
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG
NumberSOI APR-DRG Description
DRG
Type
Relative
Weight
High Outlier
Threshold
950 3 EXTENSIVE PROC UNREL PDX Surg 1.3164 28,080.88
950 4 EXTENSIVE PROC UNREL PDX Surg 6.9570 119,290.79
951 1 MOD EXTENSIVE PROC-UNREL PDX Surg 1.0220 28,739.83
951 2 MOD EXTENSIVE PROC-UNREL PDX Surg 1.0220 28,739.83
951 3 MOD EXTENSIVE PROC-UNREL PDX Surg 2.9164 28,685.16
951 4 MOD EXTENSIVE PROC-UNREL PDX Surg 2.9164 28,685.16
952 1 NONEXTENSIVE PROC-UNREL PDX Surg 0.7850 17,726.58
952 2 NONEXTENSIVE PROC-UNREL PDX Surg 0.7850 17,726.58
952 3 NONEXTENSIVE PROC-UNREL PDX Surg LV PD
952 4 NONEXTENSIVE PROC-UNREL PDX Surg LV PD
955 1 PDX INVALID AS DISCHARGE DX Not Covered NC NC
955 2 PDX INVALID AS DISCHARGE DX Not Covered NC NC
955 3 PDX INVALID AS DISCHARGE DX Not Covered NC NC
955 4 PDX INVALID AS DISCHARGE DX Not Covered NC NC
956 1 UNGROUPABLE Not Covered NC NC
956 2 UNGROUPABLE Not Covered NC NC
956 3 UNGROUPABLE Not Covered NC NC
956 4 UNGROUPABLE Not Covered NC NC
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 48
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
APR-DRG Assignment
Effective for Dates of Service on or After
July 1, 2018
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 49
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
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
APR-DRGs from version 31 by 3M Health Information
Systems
Descriptions supplied by 3M Health Information Systems
Chemical Dependency APR-DRG
1 - Minor; 2 - Moderate; 3 - Major; 4 - Extreme
Medical APR-DRG
APR-DRG is not covered by L&I
Psychiatric APR-DRG
Value Definitions
APR-DRG is not covered by L&I
Rehabilitation APR-DRG
Surgical APR-DRG
Costs minus High Outlier Threshold equals Outlier
Payment
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 50
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
The average length of stay for the APR-DRG.
On cases paid using the relative weight times the base
The highest cost necessary to qualify as a low outlier.
APR-DRG does not qualify for outlier payments
APR-DRG is not covered by L&I
Value Definitions
Payment calculated by multiplying the APR-DRG relative
weight by the Hospital base rate
Payment calculated by multiplying the Per Diem amount
by the length of stay
APR-DRG is not covered by L&I
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 51
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 52
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 7.6 PER DIEM
PD 8.6 PER DIEM
PD 12.5 PER DIEM
PD 31.6 PER DIEM
PD 9.4 PER DIEM
PD 14.7 PER DIEM
PD 21.5 PER DIEM
PD 36.7 PER DIEM
PD 16.9 PER DIEM
PD 22.6 PER DIEM
PD 32.8 PER DIEM
PD 51.2 PER DIEM
13,572.16 19.9 APR-DRG
13,572.16 20.3 APR-DRG
13,572.16 26.2 APR-DRG
13,572.16 37.8 APR-DRG
PD 17.9 PER DIEM
PD 18.5 PER DIEM
PD 23.5 PER DIEM
PD 32.0 PER DIEM
PD 5.9 PER DIEM
PD 8.1 PER DIEM
PD 10.2 PER DIEM
PD 24.7 PER DIEM
4,246.98 5.3 APR-DRG
4,246.98 6.2 APR-DRG
4,246.98 10.0 APR-DRG
4,246.98 17.1 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 53
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
2,064.14 3.9 APR-DRG
2,077.89 5.6 APR-DRG
4,246.98 10.2 APR-DRG
PD 18.6 PER DIEM
PD 2.7 PER DIEM
PD 5.1 PER DIEM
PD 10.8 PER DIEM
PD 19.0 PER DIEM
1,686.45 3.2 APR-DRG
1,686.45 5.6 APR-DRG
1,686.45 10.0 APR-DRG
1,686.45 19.6 APR-DRG
PD 1.5 PER DIEM
PD 2.8 PER DIEM
PD 7.2 PER DIEM
PD 13.6 PER DIEM
PD 2.5 PER DIEM
1,452.42 4.2 APR-DRG
1,556.27 8.6 APR-DRG
1,556.27 20.2 APR-DRG
681.97 3.5 APR-DRG
681.97 4.7 APR-DRG
681.97 7.2 APR-DRG
681.97 14.5 APR-DRG
PD 2.9 PER DIEM
PD 3.7 PER DIEM
PD 5.9 PER DIEM
PD 9.5 PER DIEM
PD 4.7 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 54
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 8.3 PER DIEM
PD 8.6 PER DIEM
PD 12.6 PER DIEM
PD 3.5 PER DIEM
PD 4.6 PER DIEM
PD 7.6 PER DIEM
PD 14.3 PER DIEM
PD 3.4 PER DIEM
PD 4.5 PER DIEM
PD 5.3 PER DIEM
PD 8.6 PER DIEM
PD 2.7 PER DIEM
PD 3.8 PER DIEM
PD 6.0 PER DIEM
PD 10.9 PER DIEM
PD 2.5 PER DIEM
PD 3.2 PER DIEM
PD 4.7 PER DIEM
PD 9.0 PER DIEM
PD 1.9 PER DIEM
PD 2.4 PER DIEM
PD 3.7 PER DIEM
PD 8.3 PER DIEM
590.97 2.7 APR-DRG
590.97 3.7 APR-DRG
590.97 5.1 APR-DRG
590.97 12.6 APR-DRG
PD 5.3 PER DIEM
PD 6.4 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 55
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 10.4 PER DIEM
PD 16.0 PER DIEM
PD 3.8 PER DIEM
PD 5.4 PER DIEM
PD 8.6 PER DIEM
PD 15.6 PER DIEM
PD 2.6 PER DIEM
PD 3.7 PER DIEM
PD 6.3 PER DIEM
PD 12.6 PER DIEM
PD 2.0 PER DIEM
PD 3.1 PER DIEM
PD 4.9 PER DIEM
PD 10.6 PER DIEM
994.04 2.2 APR-DRG
994.04 2.8 APR-DRG
597.17 4.2 APR-DRG
597.17 9.3 APR-DRG
PD 2.3 PER DIEM
PD 2.7 PER DIEM
PD 3.8 PER DIEM
PD 6.8 PER DIEM
954.50 2.2 APR-DRG
954.50 3.4 APR-DRG
954.50 5.2 APR-DRG
954.50 10.9 APR-DRG
657.31 2.2 APR-DRG
590.97 3.5 APR-DRG
648.02 5.8 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 56
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
821.59 13.1 APR-DRG
PD 1.5 PER DIEM
PD 2.3 PER DIEM
PD 4.3 PER DIEM
PD 10.1 PER DIEM
590.97 2.7 APR-DRG
PD 3.8 PER DIEM
PD 5.7 PER DIEM
1,533.64 11.4 APR-DRG
1,052.17 2.1 APR-DRG
1,052.17 3.7 APR-DRG
1,052.17 6.3 APR-DRG
1,052.17 12.8 APR-DRG
768.14 2.2 APR-DRG
PD 2.9 PER DIEM
PD 5.3 PER DIEM
PD 14.2 PER DIEM
PD 2.9 PER DIEM
PD 3.8 PER DIEM
PD 5.9 PER DIEM
PD 11.1 PER DIEM
PD 2.2 PER DIEM
PD 2.7 PER DIEM
PD 4.1 PER DIEM
PD 13.5 PER DIEM
PD 2.2 PER DIEM
PD 3.7 PER DIEM
PD 8.5 PER DIEM
PD 16.2 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 57
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 2.5 PER DIEM
PD 7.9 PER DIEM
PD 13.1 PER DIEM
PD 24.3 PER DIEM
PD 3.1 PER DIEM
PD 4.5 PER DIEM
PD 9.4 PER DIEM
PD 18.1 PER DIEM
PD 1.9 PER DIEM
PD 2.8 PER DIEM
PD 5.8 PER DIEM
PD 14.0 PER DIEM
PD 2.3 PER DIEM
PD 3.7 PER DIEM
PD 7.1 PER DIEM
PD 11.8 PER DIEM
PD 1.4 PER DIEM
PD 2.0 PER DIEM
PD 3.6 PER DIEM
PD 8.5 PER DIEM
PD 1.5 PER DIEM
PD 2.7 PER DIEM
PD 5.5 PER DIEM
PD 14.1 PER DIEM
920.50 2.0 APR-DRG
PD 3.1 PER DIEM
PD 6.5 PER DIEM
PD 14.0 PER DIEM
PD 2.8 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 58
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 4.1 PER DIEM
PD 6.6 PER DIEM
PD 12.3 PER DIEM
PD 2.0 PER DIEM
PD 2.4 PER DIEM
PD 3.4 PER DIEM
PD 7.2 PER DIEM
PD 1.9 PER DIEM
PD 2.4 PER DIEM
PD 3.8 PER DIEM
PD 7.0 PER DIEM
PD 2.1 PER DIEM
PD 2.9 PER DIEM
590.97 5.3 APR-DRG
590.97 10.4 APR-DRG
PD 2.2 PER DIEM
PD 2.9 PER DIEM
PD 4.6 PER DIEM
PD 9.2 PER DIEM
PD 4.8 PER DIEM
PD 6.7 PER DIEM
1,645.80 11.2 APR-DRG
1,645.80 19.2 APR-DRG
PD 3.4 PER DIEM
PD 5.3 PER DIEM
PD 10.0 PER DIEM
PD 18.7 PER DIEM
1,906.97 12.7 APR-DRG
1,906.97 11.8 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 59
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 13.9 PER DIEM
PD 18.7 PER DIEM
PD 6.8 PER DIEM
PD 8.1 PER DIEM
PD 10.2 PER DIEM
PD 13.0 PER DIEM
PD 3.2 PER DIEM
PD 4.0 PER DIEM
PD 6.4 PER DIEM
PD 9.2 PER DIEM
590.97 2.5 APR-DRG
701.85 4.0 APR-DRG
777.50 5.5 APR-DRG
PD 7.0 PER DIEM
800.03 3.6 APR-DRG
800.03 4.5 APR-DRG
800.03 6.2 APR-DRG
800.03 8.8 APR-DRG
590.97 2.8 APR-DRG
590.97 5.1 APR-DRG
621.12 5.6 APR-DRG
621.12 8.2 APR-DRG
778.04 3.1 APR-DRG
778.04 4.1 APR-DRG
778.04 6.4 APR-DRG
778.04 9.2 APR-DRG
PD 4.4 PER DIEM
PD 5.1 PER DIEM
838.31 7.1 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 60
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
838.31 10.1 APR-DRG
PD 2.3 PER DIEM
PD 3.1 PER DIEM
PD 5.2 PER DIEM
PD 8.7 PER DIEM
590.97 2.7 APR-DRG
590.97 3.7 APR-DRG
647.37 5.5 APR-DRG
647.37 8.7 APR-DRG
634.89 3.0 APR-DRG
634.89 3.7 APR-DRG
634.89 5.0 APR-DRG
634.89 8.6 APR-DRG
590.97 2.1 APR-DRG
590.97 3.0 APR-DRG
PD 4.2 PER DIEM
PD 5.4 PER DIEM
PD 3.2 PER DIEM
PD 4.1 PER DIEM
PD 6.1 PER DIEM
PD 10.2 PER DIEM
590.97 2.8 APR-DRG
600.93 3.6 APR-DRG
PD 5.4 PER DIEM
PD 8.2 PER DIEM
PD 2.1 PER DIEM
PD 2.9 PER DIEM
PD 4.1 PER DIEM
PD 7.0 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 61
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 4.7 PER DIEM
PD 6.1 PER DIEM
PD 9.9 PER DIEM
PD 24.4 PER DIEM
PD 3.1 PER DIEM
PD 7.7 PER DIEM
PD 15.7 PER DIEM
PD 30.5 PER DIEM
PD 7.9 PER DIEM
PD 9.1 PER DIEM
PD 13.1 PER DIEM
PD 21.0 PER DIEM
PD 5.6 PER DIEM
PD 6.4 PER DIEM
PD 9.2 PER DIEM
PD 18.0 PER DIEM
PD 6.7 PER DIEM
PD 8.1 PER DIEM
PD 10.4 PER DIEM
PD 17.0 PER DIEM
PD 5.0 PER DIEM
PD 6.0 PER DIEM
PD 8.5 PER DIEM
PD 15.8 PER DIEM
PD 4.3 PER DIEM
PD 5.7 PER DIEM
PD 9.0 PER DIEM
PD 18.0 PER DIEM
PD 4.3 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 62
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 5.6 PER DIEM
PD 9.0 PER DIEM
PD 16.5 PER DIEM
PD 4.4 PER DIEM
PD 5.2 PER DIEM
PD 8.8 PER DIEM
PD 16.0 PER DIEM
PD 2.5 PER DIEM
PD 3.8 PER DIEM
PD 6.4 PER DIEM
PD 12.9 PER DIEM
1,196.77 2.4 APR-DRG
1,196.77 4.0 APR-DRG
2,130.96 8.1 APR-DRG
PD 16.8 PER DIEM
PD 2.4 PER DIEM
PD 3.0 PER DIEM
PD 5.2 PER DIEM
PD 8.7 PER DIEM
PD 1.7 PER DIEM
PD 2.5 PER DIEM
PD 5.0 PER DIEM
PD 10.0 PER DIEM
PD 2.8 PER DIEM
PD 2.4 PER DIEM
PD 4.3 PER DIEM
PD 12.9 PER DIEM
PD 2.5 PER DIEM
PD 3.9 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 63
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 7.3 PER DIEM
PD 15.5 PER DIEM
PD 4.0 PER DIEM
PD 5.7 PER DIEM
PD 9.4 PER DIEM
PD 15.7 PER DIEM
PD 2.1 PER DIEM
PD 3.1 PER DIEM
PD 5.1 PER DIEM
PD 8.0 PER DIEM
PD 2.4 PER DIEM
PD 3.5 PER DIEM
PD 5.7 PER DIEM
PD 11.6 PER DIEM
PD 1.9 PER DIEM
PD 2.5 PER DIEM
PD 4.3 PER DIEM
PD 8.0 PER DIEM
PD 5.2 PER DIEM
PD 6.7 PER DIEM
PD 9.8 PER DIEM
PD 14.7 PER DIEM
PD 2.8 PER DIEM
PD 3.7 PER DIEM
PD 5.5 PER DIEM
PD 9.4 PER DIEM
PD 2.2 PER DIEM
PD 2.2 PER DIEM
PD 2.4 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 64
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 4.5 PER DIEM
590.97 3.2 APR-DRG
590.97 3.9 APR-DRG
967.80 5.3 APR-DRG
PD 9.8 PER DIEM
PD 1.6 PER DIEM
PD 2.1 PER DIEM
PD 3.3 PER DIEM
PD 7.4 PER DIEM
PD 1.9 PER DIEM
PD 2.5 PER DIEM
PD 3.9 PER DIEM
PD 7.6 PER DIEM
PD 2.3 PER DIEM
PD 3.1 PER DIEM
PD 5.0 PER DIEM
PD 9.7 PER DIEM
PD 1.9 PER DIEM
PD 2.8 PER DIEM
590.97 4.5 APR-DRG
590.97 7.7 APR-DRG
590.97 1.4 APR-DRG
590.97 1.9 APR-DRG
590.97 3.0 APR-DRG
590.97 7.0 APR-DRG
PD 2.0 PER DIEM
PD 2.6 PER DIEM
590.97 3.8 APR-DRG
590.97 8.3 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 65
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 2.3 PER DIEM
PD 2.9 PER DIEM
PD 4.8 PER DIEM
PD 9.5 PER DIEM
PD 2.2 PER DIEM
PD 3.3 PER DIEM
PD 5.4 PER DIEM
PD 10.9 PER DIEM
PD 2.3 PER DIEM
PD 3.2 PER DIEM
PD 4.7 PER DIEM
PD 8.2 PER DIEM
PD 3.6 PER DIEM
2,647.86 7.1 APR-DRG
PD 11.9 PER DIEM
PD 20.8 PER DIEM
1,263.41 4.8 APR-DRG
1,263.41 7.0 APR-DRG
PD 12.0 PER DIEM
PD 20.0 PER DIEM
PD 2.2 PER DIEM
PD 3.5 PER DIEM
PD 8.1 PER DIEM
PD 17.6 PER DIEM
PD 4.3 PER DIEM
PD 6.3 PER DIEM
PD 10.7 PER DIEM
PD 19.1 PER DIEM
PD 5.3 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 66
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 7.7 PER DIEM
PD 11.3 PER DIEM
PD 17.4 PER DIEM
PD 1.5 PER DIEM
PD 3.7 PER DIEM
PD 7.1 PER DIEM
PD 13.2 PER DIEM
PD 2.5 PER DIEM
PD 4.0 PER DIEM
PD 7.1 PER DIEM
PD 12.8 PER DIEM
603.39 2.8 APR-DRG
778.79 4.3 APR-DRG
PD 7.9 PER DIEM
PD 14.8 PER DIEM
590.97 1.9 APR-DRG
590.97 3.3 APR-DRG
PD 6.1 PER DIEM
PD 12.9 PER DIEM
PD 3.7 PER DIEM
1,622.68 5.4 APR-DRG
PD 9.5 PER DIEM
PD 17.8 PER DIEM
PD 3.5 PER DIEM
PD 4.1 PER DIEM
PD 6.6 PER DIEM
PD 11.9 PER DIEM
711.37 2.5 APR-DRG
PD 3.2 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 67
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
808.47 4.7 APR-DRG
PD 10.0 PER DIEM
PD 2.2 PER DIEM
PD 3.1 PER DIEM
PD 4.5 PER DIEM
PD 9.9 PER DIEM
PD 1.8 PER DIEM
PD 2.7 PER DIEM
PD 4.6 PER DIEM
PD 10.0 PER DIEM
PD 2.9 PER DIEM
PD 3.5 PER DIEM
PD 5.3 PER DIEM
PD 10.6 PER DIEM
PD 3.3 PER DIEM
PD 4.0 PER DIEM
PD 6.1 PER DIEM
PD 11.7 PER DIEM
PD 3.1 PER DIEM
PD 3.9 PER DIEM
PD 5.9 PER DIEM
PD 10.2 PER DIEM
PD 2.8 PER DIEM
PD 3.7 PER DIEM
PD 5.8 PER DIEM
PD 10.9 PER DIEM
PD 3.3 PER DIEM
PD 4.6 PER DIEM
PD 7.0 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 68
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 12.1 PER DIEM
PD 2.1 PER DIEM
PD 2.8 PER DIEM
PD 4.2 PER DIEM
PD 9.1 PER DIEM
590.97 2.1 APR-DRG
590.97 2.8 APR-DRG
PD 4.0 PER DIEM
PD 7.7 PER DIEM
PD 3.2 PER DIEM
PD 4.0 PER DIEM
PD 6.1 PER DIEM
PD 11.8 PER DIEM
590.97 2.5 APR-DRG
590.97 3.3 APR-DRG
PD 4.9 PER DIEM
PD 8.9 PER DIEM
590.97 2.4 APR-DRG
590.97 3.4 APR-DRG
590.97 5.1 APR-DRG
PD 10.1 PER DIEM
PD 4.6 PER DIEM
PD 6.0 PER DIEM
PD 10.6 PER DIEM
PD 21.5 PER DIEM
PD 4.5 PER DIEM
PD 6.9 PER DIEM
PD 11.0 PER DIEM
PD 19.3 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 69
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 4.0 PER DIEM
PD 5.6 PER DIEM
PD 8.9 PER DIEM
PD 17.0 PER DIEM
PD 2.3 PER DIEM
PD 3.6 PER DIEM
PD 6.2 PER DIEM
PD 13.5 PER DIEM
PD 4.3 PER DIEM
PD 5.3 PER DIEM
PD 10.3 PER DIEM
PD 21.2 PER DIEM
PD 2.7 PER DIEM
PD 3.5 PER DIEM
PD 5.6 PER DIEM
PD 11.4 PER DIEM
PD 2.8 PER DIEM
PD 3.3 PER DIEM
PD 5.2 PER DIEM
PD 10.4 PER DIEM
PD 3.3 PER DIEM
PD 4.1 PER DIEM
PD 5.9 PER DIEM
PD 9.4 PER DIEM
PD 3.1 PER DIEM
PD 3.9 PER DIEM
PD 6.3 PER DIEM
PD 13.6 PER DIEM
592.62 2.8 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 70
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
592.62 3.3 APR-DRG
590.97 4.9 APR-DRG
590.97 9.0 APR-DRG
PD 2.4 PER DIEM
PD 3.4 PER DIEM
PD 5.2 PER DIEM
PD 10.4 PER DIEM
1,611.07 3.6 APR-DRG
1,611.07 3.9 APR-DRG
1,647.74 5.2 APR-DRG
1,647.74 12.7 APR-DRG
1,240.65 2.9 APR-DRG
1,240.65 3.3 APR-DRG
1,467.76 5.0 APR-DRG
1,240.65 12.4 APR-DRG
PD 4.4 PER DIEM
PD 5.6 PER DIEM
PD 8.3 PER DIEM
PD 15.8 PER DIEM
2,592.02 2.9 APR-DRG
2,592.02 4.0 APR-DRG
2,877.62 7.1 APR-DRG
2,877.62 17.4 APR-DRG
1,546.38 5.2 APR-DRG
1,546.38 7.2 APR-DRG
1,546.38 11.0 APR-DRG
1,546.38 19.4 APR-DRG
1,433.26 4.1 APR-DRG
1,433.26 4.9 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 71
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
1,433.26 6.8 APR-DRG
1,433.26 12.5 APR-DRG
798.86 2.7 APR-DRG
950.91 4.7 APR-DRG
PD 8.4 PER DIEM
PD 18.2 PER DIEM
PD 1.8 PER DIEM
PD 2.9 PER DIEM
PD 6.1 PER DIEM
PD 15.8 PER DIEM
1,068.11 5.2 APR-DRG
1,068.11 8.7 APR-DRG
1,361.88 18.0 APR-DRG
1,361.88 32.3 APR-DRG
878.41 2.6 APR-DRG
771.38 4.2 APR-DRG
1,003.34 7.5 APR-DRG
998.02 16.3 APR-DRG
822.37 2.4 APR-DRG
822.37 4.9 APR-DRG
PD 7.8 PER DIEM
PD 15.2 PER DIEM
623.67 1.8 APR-DRG
594.62 2.6 APR-DRG
594.62 6.2 APR-DRG
1,358.26 14.3 APR-DRG
602.59 2.2 APR-DRG
827.93 3.8 APR-DRG
743.99 7.0 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 72
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
743.99 14.1 APR-DRG
1,092.38 2.9 APR-DRG
628.24 5.2 APR-DRG
731.15 9.6 APR-DRG
731.15 19.7 APR-DRG
828.47 2.2 APR-DRG
1,729.09 4.5 APR-DRG
2,237.55 8.6 APR-DRG
PD 17.6 PER DIEM
1,140.19 1.7 APR-DRG
1,422.54 3.1 APR-DRG
3,433.94 8.4 APR-DRG
5,183.07 17.3 APR-DRG
PD 2.9 PER DIEM
PD 3.3 PER DIEM
PD 4.9 PER DIEM
PD 6.9 PER DIEM
607.09 2.9 APR-DRG
607.09 3.6 APR-DRG
607.09 4.7 APR-DRG
607.09 9.8 APR-DRG
590.97 2.1 APR-DRG
PD 3.2 PER DIEM
590.97 5.0 APR-DRG
PD 10.6 PER DIEM
700.11 3.6 APR-DRG
829.78 4.5 APR-DRG
854.51 7.4 APR-DRG
1,482.31 12.6 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 73
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
925.05 4.6 APR-DRG
685.84 5.8 APR-DRG
685.84 9.6 APR-DRG
685.84 16.8 APR-DRG
590.97 3.0 APR-DRG
590.97 4.0 APR-DRG
590.97 7.1 APR-DRG
PD 15.0 PER DIEM
590.97 2.8 APR-DRG
590.97 3.8 APR-DRG
590.97 5.2 APR-DRG
590.97 11.6 APR-DRG
621.05 2.2 APR-DRG
621.05 4.4 APR-DRG
621.05 7.2 APR-DRG
621.05 13.3 APR-DRG
590.97 2.4 APR-DRG
590.97 3.4 APR-DRG
618.67 5.2 APR-DRG
PD 10.9 PER DIEM
798.79 3.9 APR-DRG
762.78 7.2 APR-DRG
761.92 13.0 APR-DRG
842.42 27.2 APR-DRG
PD 1.7 PER DIEM
PD 2.3 PER DIEM
PD 5.7 PER DIEM
PD 13.4 PER DIEM
1,490.18 2.0 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 74
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 3.1 PER DIEM
PD 5.1 PER DIEM
PD 17.1 PER DIEM
607.35 2.8 APR-DRG
874.42 4.9 APR-DRG
1,133.44 8.9 APR-DRG
1,273.55 18.3 APR-DRG
676.09 3.9 APR-DRG
676.09 4.7 APR-DRG
676.09 7.2 APR-DRG
676.09 15.5 APR-DRG
PD 2.9 PER DIEM
711.57 4.1 APR-DRG
PD 6.5 PER DIEM
PD 13.6 PER DIEM
PD 3.1 PER DIEM
PD 4.1 PER DIEM
PD 6.2 PER DIEM
PD 9.6 PER DIEM
590.97 2.9 APR-DRG
590.97 4.0 APR-DRG
PD 6.0 PER DIEM
PD 11.6 PER DIEM
590.97 1.9 APR-DRG
590.97 2.9 APR-DRG
PD 4.7 PER DIEM
PD 10.8 PER DIEM
PD 2.4 PER DIEM
PD 3.4 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 75
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 5.4 PER DIEM
PD 12.6 PER DIEM
PD 3.0 PER DIEM
PD 4.1 PER DIEM
PD 8.2 PER DIEM
PD 23.0 PER DIEM
PD 1.8 PER DIEM
PD 2.2 PER DIEM
PD 4.7 PER DIEM
PD 18.0 PER DIEM
PD 1.3 PER DIEM
PD 2.1 PER DIEM
PD 6.4 PER DIEM
PD 16.2 PER DIEM
PD 3.9 PER DIEM
PD 5.4 PER DIEM
PD 9.3 PER DIEM
PD 21.2 PER DIEM
PD 2.5 PER DIEM
PD 2.7 PER DIEM
PD 4.1 PER DIEM
PD 9.2 PER DIEM
PD 3.3 PER DIEM
PD 4.5 PER DIEM
PD 6.3 PER DIEM
PD 13.1 PER DIEM
PD 1.9 PER DIEM
PD 2.8 PER DIEM
PD 4.3 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 76
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 8.8 PER DIEM
PD 2.6 PER DIEM
PD 3.5 PER DIEM
PD 5.5 PER DIEM
PD 14.7 PER DIEM
590.97 2.5 APR-DRG
PD 3.8 PER DIEM
PD 5.8 PER DIEM
PD 11.2 PER DIEM
PD 2.3 PER DIEM
PD 2.9 PER DIEM
PD 4.5 PER DIEM
PD 9.2 PER DIEM
PD 4.6 PER DIEM
PD 5.6 PER DIEM
PD 8.6 PER DIEM
PD 20.9 PER DIEM
PD 4.6 PER DIEM
PD 7.2 PER DIEM
PD 9.7 PER DIEM
PD 21.4 PER DIEM
PD 3.2 PER DIEM
PD 4.1 PER DIEM
PD 7.8 PER DIEM
PD 16.5 PER DIEM
PD 2.5 PER DIEM
PD 3.4 PER DIEM
PD 7.8 PER DIEM
PD 17.0 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 77
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 2.5 PER DIEM
PD 4.3 PER DIEM
PD 8.9 PER DIEM
PD 15.7 PER DIEM
PD 1.8 PER DIEM
PD 3.1 PER DIEM
PD 7.7 PER DIEM
PD 14.5 PER DIEM
PD 1.8 PER DIEM
PD 2.5 PER DIEM
PD 5.9 PER DIEM
PD 13.1 PER DIEM
PD 2.2 PER DIEM
PD 3.5 PER DIEM
PD 7.0 PER DIEM
PD 17.4 PER DIEM
PD 2.8 PER DIEM
PD 3.6 PER DIEM
PD 4.8 PER DIEM
PD 10.9 PER DIEM
PD 2.6 PER DIEM
PD 3.6 PER DIEM
590.97 5.8 APR-DRG
590.97 10.8 APR-DRG
PD 2.5 PER DIEM
PD 3.6 PER DIEM
PD 6.3 PER DIEM
PD 13.3 PER DIEM
PD 2.6 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 78
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 3.4 PER DIEM
PD 4.9 PER DIEM
PD 8.8 PER DIEM
PD 1.6 PER DIEM
PD 2.0 PER DIEM
PD 3.7 PER DIEM
PD 8.4 PER DIEM
818.94 2.1 APR-DRG
818.94 3.3 APR-DRG
946.86 5.2 APR-DRG
946.86 9.4 APR-DRG
590.97 2.4 APR-DRG
590.97 3.2 APR-DRG
PD 4.9 PER DIEM
PD 10.1 PER DIEM
PD 1.8 PER DIEM
PD 2.3 PER DIEM
PD 6.0 PER DIEM
PD 14.4 PER DIEM
PD 2.2 PER DIEM
PD 2.5 PER DIEM
PD 8.2 PER DIEM
PD 18.4 PER DIEM
PD 1.7 PER DIEM
PD 2.7 PER DIEM
PD 7.0 PER DIEM
PD 13.0 PER DIEM
PD 1.9 PER DIEM
PD 5.2 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 79
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
590.97 10.6 APR-DRG
590.97 19.5 APR-DRG
PD 2.5 PER DIEM
PD 1.9 PER DIEM
PD 4.8 PER DIEM
PD 16.4 PER DIEM
PD 2.5 PER DIEM
PD 4.1 PER DIEM
PD 5.8 PER DIEM
PD 10.6 PER DIEM
PD 2.5 PER DIEM
PD 3.4 PER DIEM
PD 5.2 PER DIEM
PD 10.7 PER DIEM
PD 2.4 PER DIEM
PD 3.8 PER DIEM
PD 8.8 PER DIEM
PD 17.5 PER DIEM
PD 3.2 PER DIEM
PD 4.8 PER DIEM
PD 8.5 PER DIEM
PD 17.4 PER DIEM
PD 2.1 PER DIEM
PD 3.0 PER DIEM
PD 6.7 PER DIEM
PD 16.0 PER DIEM
PD 1.8 PER DIEM
PD 2.4 PER DIEM
PD 5.5 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 80
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 14.5 PER DIEM
PD 1.4 PER DIEM
PD 1.7 PER DIEM
PD 5.0 PER DIEM
PD 14.9 PER DIEM
PD 1.9 PER DIEM
PD 2.8 PER DIEM
PD 6.3 PER DIEM
PD 12.7 PER DIEM
PD 2.2 PER DIEM
PD 3.7 PER DIEM
PD 8.2 PER DIEM
PD 18.2 PER DIEM
PD 2.0 PER DIEM
PD 2.7 PER DIEM
PD 5.9 PER DIEM
PD 14.3 PER DIEM
PD 2.7 PER DIEM
PD 3.7 PER DIEM
PD 6.1 PER DIEM
PD 11.2 PER DIEM
PD 2.6 PER DIEM
PD 3.7 PER DIEM
PD 6.2 PER DIEM
PD 12.1 PER DIEM
PD 1.7 PER DIEM
PD 2.3 PER DIEM
PD 4.2 PER DIEM
PD 9.2 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 81
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 3.0 PER DIEM
PD 3.8 PER DIEM
PD 6.0 PER DIEM
PD 10.3 PER DIEM
PD 2.1 PER DIEM
PD 2.4 PER DIEM
PD 4.6 PER DIEM
PD 8.2 PER DIEM
PD 2.2 PER DIEM
PD 2.7 PER DIEM
PD 5.4 PER DIEM
PD 10.4 PER DIEM
PD 1.3 PER DIEM
PD 1.9 PER DIEM
PD 3.8 PER DIEM
PD 8.3 PER DIEM
PD 1.6 PER DIEM
PD 1.9 PER DIEM
PD 2.6 PER DIEM
PD 5.1 PER DIEM
PD 2.6 PER DIEM
PD 4.0 PER DIEM
PD 7.1 PER DIEM
PD 14.0 PER DIEM
PD 2.0 PER DIEM
PD 2.3 PER DIEM
PD 3.6 PER DIEM
PD 8.5 PER DIEM
PD 2.1 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 82
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 2.5 PER DIEM
PD 3.8 PER DIEM
PD 6.6 PER DIEM
PD 2.4 PER DIEM
PD 3.6 PER DIEM
PD 7.0 PER DIEM
PD 7.9 PER DIEM
PD 1.3 PER DIEM
PD 1.6 PER DIEM
PD 2.7 PER DIEM
PD 6.6 PER DIEM
PD 1.2 PER DIEM
PD 1.7 PER DIEM
PD 6.0 PER DIEM
PD 6.6 PER DIEM
PD 2.0 PER DIEM
PD 2.8 PER DIEM
PD 5.1 PER DIEM
PD 8.2 PER DIEM
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
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: 83
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
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: 84
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
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: 85
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
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: 86
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
PD 3.4 PER DIEM
PD 5.2 PER DIEM
PD 8.4 PER DIEM
PD 15.4 PER DIEM
PD 3.2 PER DIEM
PD 4.6 PER DIEM
590.97 9.1 APR-DRG
PD 23.6 PER DIEM
PD 3.0 PER DIEM
PD 4.0 PER DIEM
PD 6.3 PER DIEM
PD 13.8 PER DIEM
PD 2.7 PER DIEM
PD 3.6 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 87
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 5.4 PER DIEM
PD 12.1 PER DIEM
PD 4.0 PER DIEM
PD 5.2 PER DIEM
PD 7.6 PER DIEM
PD 12.9 PER DIEM
590.97 2.3 APR-DRG
590.97 2.9 APR-DRG
PD 4.4 PER DIEM
PD 8.6 PER DIEM
PD 4.0 PER DIEM
PD 6.1 PER DIEM
PD 11.6 PER DIEM
PD 24.0 PER DIEM
PD 2.6 PER DIEM
PD 4.9 PER DIEM
PD 10.8 PER DIEM
PD 24.5 PER DIEM
PD 4.6 PER DIEM
PD 7.1 PER DIEM
PD 14.3 PER DIEM
PD 25.1 PER DIEM
PD 3.7 PER DIEM
PD 5.2 PER DIEM
PD 8.3 PER DIEM
PD 15.6 PER DIEM
PD 3.6 PER DIEM
PD 4.6 PER DIEM
PD 8.4 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 88
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 14.5 PER DIEM
PD 2.8 PER DIEM
PD 3.6 PER DIEM
PD 7.5 PER DIEM
PD 23.7 PER DIEM
PD 2.9 PER DIEM
PD 3.9 PER DIEM
PD 6.5 PER DIEM
PD 11.4 PER DIEM
902.23 4.7 APR-DRG
902.23 6.6 APR-DRG
902.23 10.9 APR-DRG
902.23 18.2 APR-DRG
738.57 4.5 APR-DRG
738.57 6.6 APR-DRG
PD 10.9 PER DIEM
PD 20.5 PER DIEM
832.58 3.4 APR-DRG
832.58 4.3 APR-DRG
1,234.12 6.3 APR-DRG
1,234.12 10.1 APR-DRG
590.97 3.5 APR-DRG
590.97 4.5 APR-DRG
590.97 6.8 APR-DRG
590.97 11.1 APR-DRG
PD 2.2 PER DIEM
PD 2.9 PER DIEM
PD 4.2 PER DIEM
PD 7.1 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 89
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 2.1 PER DIEM
PD 2.7 PER DIEM
PD 4.5 PER DIEM
PD 12.6 PER DIEM
590.97 3.9 APR-DRG
590.97 4.6 APR-DRG
712.88 6.5 APR-DRG
712.88 12.9 APR-DRG
PD 6.2 PER DIEM
PD 12.8 PER DIEM
PD 20.3 PER DIEM
PD 24.2 PER DIEM
PD 10.8 PER DIEM
PD 11.8 PER DIEM
PD 15.4 PER DIEM
PD 28.5 PER DIEM
PD 7.3 PER DIEM
PD 10.2 PER DIEM
PD 14.4 PER DIEM
PD 20.3 PER DIEM
PD 5.0 PER DIEM
PD 6.6 PER DIEM
PD 14.7 PER DIEM
PD 73.0 PER DIEM
PD 6.0 PER DIEM
PD 8.1 PER DIEM
PD 12.1 PER DIEM
PD 19.5 PER DIEM
PD 4.2 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 90
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 5.6 PER DIEM
PD 7.3 PER DIEM
PD 16.6 PER DIEM
PD 3.9 PER DIEM
PD 6.2 PER DIEM
PD 9.0 PER DIEM
PD 8.1 PER DIEM
PD 3.3 PER DIEM
PD 3.8 PER DIEM
PD 4.6 PER DIEM
PD 9.4 PER DIEM
PD 8.7 PER DIEM
PD 9.3 PER DIEM
PD 10.9 PER DIEM
PD 16.4 PER DIEM
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
PD 19.9 PER DIEM
PD 13.0 PER DIEM
PD 14.0 PER DIEM
PD 23.0 PER DIEM
PD 7.5 PER DIEM
PD 7.7 PER DIEM
PD 9.1 PER DIEM
PD 12.0 PER DIEM
PD 2.5 PER DIEM
PD 2.5 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 91
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 3.3 PER DIEM
PD 7.9 PER DIEM
PD 14.3 PER DIEM
PD 15.5 PER DIEM
PD 12.9 PER DIEM
PD 23.9 PER DIEM
PD 3.4 PER DIEM
PD 4.1 PER DIEM
PD 5.1 PER DIEM
PD 9.9 PER DIEM
PD 3.7 PER DIEM
PD 4.1 PER DIEM
PD 4.8 PER DIEM
PD 14.2 PER DIEM
PD 3.2 PER DIEM
PD 3.8 PER DIEM
PD 5.7 PER DIEM
PD 12.6 PER DIEM
PD 3.9 PER DIEM
PD 4.0 PER DIEM
PD 5.0 PER DIEM
PD 9.3 PER DIEM
PD 3.0 PER DIEM
PD 4.9 PER DIEM
PD 9.4 PER DIEM
PD 19.5 PER DIEM
PD 1.5 PER DIEM
PD 2.0 PER DIEM
PD 3.8 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 92
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 8.9 PER DIEM
590.97 1.6 APR-DRG
590.97 2.2 APR-DRG
590.97 3.3 APR-DRG
590.97 6.7 APR-DRG
741.31 2.5 APR-DRG
741.31 3.3 APR-DRG
1,141.95 5.5 APR-DRG
1,141.95 12.1 APR-DRG
590.97 1.6 APR-DRG
590.97 2.6 APR-DRG
590.97 4.2 APR-DRG
PD 8.3 PER DIEM
PD 1.7 PER DIEM
PD 2.3 PER DIEM
PD 3.3 PER DIEM
PD 7.0 PER DIEM
PD 22.0 PER DIEM
PD 23.0 PER DIEM
PD 24.2 PER DIEM
PD 41.0 PER DIEM
1,504.76 7.3 APR-DRG
1,504.76 10.4 APR-DRG
PD 16.9 PER DIEM
PD 29.1 PER DIEM
590.97 3.2 APR-DRG
PD 4.6 PER DIEM
PD 6.8 PER DIEM
PD 10.1 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 93
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
641.64 3.0 APR-DRG
641.64 4.8 APR-DRG
2,093.79 7.2 APR-DRG
2,093.79 18.2 APR-DRG
PD 2.7 PER DIEM
PD 6.6 PER DIEM
PD 16.2 PER DIEM
PD 31.6 PER DIEM
PD 9.3 PER DIEM
PD 11.5 PER DIEM
PD 14.8 PER DIEM
PD 18.0 PER DIEM
590.97 2.4 APR-DRG
602.80 3.2 APR-DRG
PD 1.7 PER DIEM
PD 8.9 PER DIEM
PD 6.3 PER DIEM
PD 10.1 PER DIEM
PD 12.4 PER DIEM
PD 16.8 PER DIEM
PD 8.3 PER DIEM
PD 17.6 PER DIEM
PD 27.3 PER DIEM
PD 47.5 PER DIEM
PD 1.7 PER DIEM
PD 6.6 PER DIEM
PD 8.8 PER DIEM
PD 14.8 PER DIEM
PD 5.6 PER DIEM
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 94
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
PD 4.8 PER DIEM
PD 6.4 PER DIEM
PD 11.0 PER DIEM
PD 4.6 PER DIEM
PD 4.8 PER DIEM
PD 7.5 PER DIEM
PD 13.3 PER DIEM
PD 3.2 PER DIEM
PD 3.8 PER DIEM
PD 5.8 PER DIEM
PD 10.0 PER DIEM
PD 7.8 PER DIEM
PD 10.6 PER DIEM
4,884.06 11.0 APR-DRG
4,884.06 19.8 APR-DRG
PD 5.1 PER DIEM
PD 6.2 PER DIEM
PD 8.1 PER DIEM
PD 17.5 PER DIEM
1,311.09 5.6 APR-DRG
2,876.60 6.0 APR-DRG
2,339.58 9.6 APR-DRG
3,405.56 17.8 APR-DRG
896.08 3.0 APR-DRG
896.08 3.7 APR-DRG
1,133.74 5.8 APR-DRG
1,746.61 12.2 APR-DRG
1,460.21 3.4 APR-DRG
1,460.21 6.0 APR-DRG
L&I uses APR-DRG Version 31 copyright 3M Health Information Systems. Refer to Field Key for definitions APR-DRG Assignment Page: 95
Facilities Fee Schedule
APR-DRG Assignment
Effective July 1, 2018
Low Outlier
Threshold
Avg
LOS
Paid
Using
1,460.21 11.4 APR-DRG
5,972.18 22.1 APR-DRG
1,679.91 3.0 APR-DRG
1,679.91 5.0 APR-DRG
1,897.18 9.7 APR-DRG
1,897.18 18.9 APR-DRG
753.60 2.6 APR-DRG
753.60 4.8 APR-DRG
PD 9.3 PER DIEM
PD 18.0 PER DIEM
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
NC NC Not Covered
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: 96
