Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage0.9753

0001 1 LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT 9.8146 9.1050 8.8801 6.17 24,000$ 30,000$ 100% 30,000$ 20%

0001 2 LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT 9.8569 9.1442 8.9183 7.96 24,000 30,000 100% 30,000 20%

0001 3 LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT 11.6116 10.7721 10.5060 12.10 24,000 30,000 100% 30,000 20%

0001 4 LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT 19.9489 18.5066 18.0495 26.98 24,000 30,000 100% 30,000 20%

0002 1 HEART &/OR LUNG TRANSPLANT 11.8664 11.0085 10.7366 9.86 24,000 30,000 100% 30,000 20%

0002 2 HEART &/OR LUNG TRANSPLANT 12.9082 11.9749 11.6791 14.29 24,000 30,000 100% 30,000 20%

0002 3 HEART &/OR LUNG TRANSPLANT 15.5234 14.4011 14.0454 22.69 24,000 30,000 100% 30,000 20%

0002 4 HEART &/OR LUNG TRANSPLANT 28.9732 26.8784 26.2145 37.47 24,000 30,000 100% 30,000 20%

0003 1 BONE MARROW TRANSPLANT 6.4589 5.9919 5.8439 17.55 24,000 30,000 100% 30,000 20%

0003 2 BONE MARROW TRANSPLANT 8.9497 8.3026 8.0975 25.95 24,000 30,000 100% 30,000 20%

0003 3 BONE MARROW TRANSPLANT 15.3147 14.2074 13.8565 39.51 24,000 30,000 100% 30,000 20%

0003 4 BONE MARROW TRANSPLANT 26.4695 24.5558 23.9493 52.56 24,000 30,000 100% 30,000 20%

0004 1 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 8.5101 7.8948 7.6998 15.92 24,000 30,000 80% 30,000 20%

0004 2 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 8.5211 7.9050 7.7097 21.66 24,000 30,000 80% 30,000 20%

0004 3 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 11.8922 11.0324 10.7599 31.19 24,000 30,000 80% 30,000 20%

0004 4 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 19.4387 18.0333 17.5879 43.56 24,000 30,000 80% 30,000 20%

0005 1 TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE 6.8040 6.3121 6.1562 23.12 24,000 30,000 80% 30,000 20%

0005 2 TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE 6.7866 6.2959 6.1404 19.86 24,000 30,000 80% 30,000 20%

0005 3 TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE 9.2714 8.6011 8.3887 26.76 24,000 30,000 80% 30,000 20%

0005 4 TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE 13.7288 12.7362 12.4216 35.52 24,000 30,000 80% 30,000 20%

0006 1 PANCREAS TRANSPLANT 8.1103 7.5239 7.3381 7.29 24,000 30,000 100% 30,000 20%

0006 2 PANCREAS TRANSPLANT 8.1103 7.5239 7.3381 7.29 24,000 30,000 100% 30,000 20%

0006 3 PANCREAS TRANSPLANT 8.1103 7.5239 7.3381 9.61 24,000 30,000 100% 30,000 20%

0006 4 PANCREAS TRANSPLANT 8.1103 7.5239 7.3381 20.44 24,000 30,000 100% 30,000 20%

0020 1 CRANIOTOMY FOR TRAUMA 1.7172 1.5930 1.5537 5.42 24,000 30,000 80% 30,000 20%

0020 2 CRANIOTOMY FOR TRAUMA 2.3961 2.2229 2.1680 6.59 24,000 30,000 80% 30,000 20%

0020 3 CRANIOTOMY FOR TRAUMA 3.5127 3.2587 3.1782 10.25 24,000 30,000 80% 30,000 20%

0020 4 CRANIOTOMY FOR TRAUMA 6.6514 6.1705 6.0181 18.12 24,000 30,000 80% 30,000 20%

0021 1 CRANIOTOMY EXCEPT FOR TRAUMA 1.8544 1.7203 1.6778 4.30 24,000 30,000 80% 30,000 20%

0021 2 CRANIOTOMY EXCEPT FOR TRAUMA 2.5694 2.3836 2.3247 6.23 24,000 30,000 80% 30,000 20%

0021 3 CRANIOTOMY EXCEPT FOR TRAUMA 5.0948 4.7264 4.6097 12.06 24,000 30,000 80% 30,000 20%

0021 4 CRANIOTOMY EXCEPT FOR TRAUMA 8.9170 8.2723 8.0680 21.39 24,000 30,000 80% 30,000 20%

0022 1 VENTRICULAR SHUNT PROCEDURES 1.0840 1.0056 0.9808 2.56 24,000 30,000 80% 30,000 20%

0022 2 VENTRICULAR SHUNT PROCEDURES 1.4468 1.3422 1.3090 4.10 24,000 30,000 80% 30,000 20%

0022 3 VENTRICULAR SHUNT PROCEDURES 3.6044 3.3438 3.2612 10.75 24,000 30,000 80% 30,000 20%

0022 4 VENTRICULAR SHUNT PROCEDURES 8.0485 7.4666 7.2822 20.80 24,000 30,000 80% 30,000 20%

0023 1 SPINAL PROCEDURES 1.3415 1.2445 1.2138 2.97 24,000 30,000 80% 30,000 20%

0023 2 SPINAL PROCEDURES 2.0598 1.9109 1.8637 5.48 24,000 30,000 80% 30,000 20%

0023 3 SPINAL PROCEDURES 3.1525 2.9246 2.8524 9.93 24,000 30,000 80% 30,000 20%

0023 4 SPINAL PROCEDURES 8.1122 7.5257 7.3398 21.57 24,000 30,000 80% 30,000 20%

0024 1 EXTRACRANIAL VASCULAR PROCEDURES 1.1110 1.0307 1.0052 1.44 24,000 30,000 80% 30,000 20%

0024 2 EXTRACRANIAL VASCULAR PROCEDURES 1.4883 1.3807 1.3466 2.38 24,000 30,000 80% 30,000 20%

0024 3 EXTRACRANIAL VASCULAR PROCEDURES 3.1395 2.9125 2.8406 6.64 24,000 30,000 80% 30,000 20%

0024 4 EXTRACRANIAL VASCULAR PROCEDURES 7.6599 7.1061 6.9306 15.20 24,000 30,000 80% 30,000 20%

0026 1 OTHER NERVOUS SYSTEM & RELATED PROCEDURES 1.0421 0.9668 0.9429 2.23 24,000 30,000 80% 30,000 20%

0026 2 OTHER NERVOUS SYSTEM & RELATED PROCEDURES 1.7240 1.5994 1.5599 3.85 24,000 30,000 80% 30,000 20%

0026 3 OTHER NERVOUS SYSTEM & RELATED PROCEDURES 2.8216 2.6176 2.5529 8.73 24,000 30,000 80% 30,000 20%

0026 4 OTHER NERVOUS SYSTEM & RELATED PROCEDURES 9.0265 8.3739 8.1671 20.93 24,000 30,000 80% 30,000 20%

0040 1 SPINAL DISORDERS & INJURIES 0.8063 0.7480 0.7295 3.14 24,000 30,000 80% 30,000 20%

0040 2 SPINAL DISORDERS & INJURIES 1.1003 1.0207 0.9955 4.81 24,000 30,000 80% 30,000 20%

0040 3 SPINAL DISORDERS & INJURIES 2.0675 1.9180 1.8706 6.66 24,000 30,000 80% 30,000 20%

0040 4 SPINAL DISORDERS & INJURIES 2.5272 2.3445 2.2866 13.96 24,000 30,000 80% 30,000 20%

0041 1 NERVOUS SYSTEM MALIGNANCY 0.7194 0.6674 0.6509 2.93 24,000 30,000 80% 30,000 20%

0041 2 NERVOUS SYSTEM MALIGNANCY 0.8673 0.8046 0.7847 3.88 24,000 30,000 80% 30,000 20%

0041 3 NERVOUS SYSTEM MALIGNANCY 1.6214 1.5042 1.4670 6.46 24,000 30,000 80% 30,000 20%

0041 4 NERVOUS SYSTEM MALIGNANCY 3.2351 3.0012 2.9271 10.32 24,000 30,000 80% 30,000 20%

0042 1 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 0.5726 0.5312 0.5181 4.15 24,000 30,000 80% 30,000 20%

0042 2 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 0.9230 0.8563 0.8351 6.66 24,000 30,000 80% 30,000 20%

0042 3 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 1.5893 1.4744 1.4380 7.55 24,000 30,000 80% 30,000 20%

0042 4 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 4.0743 3.7797 3.6863 11.72 24,000 30,000 80% 30,000 20%

0043 1 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES 0.6709 0.6224 0.6070 3.44 24,000 30,000 80% 30,000 20%

0043 2 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES 0.8490 0.7876 0.7681 4.62 24,000 30,000 80% 30,000 20%

0043 3 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES 1.8009 1.6707 1.6294 7.76 24,000 30,000 80% 30,000 20%

0043 4 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES 4.3965 4.0786 3.9779 13.63 24,000 30,000 80% 30,000 20%

0044 1 INTRACRANIAL HEMORRHAGE 0.9608 0.8913 0.8693 3.54 24,000 30,000 80% 30,000 20%

0044 2 INTRACRANIAL HEMORRHAGE 1.3456 1.2483 1.2175 4.59 24,000 30,000 80% 30,000 20%

0044 3 INTRACRANIAL HEMORRHAGE 1.8460 1.7125 1.6702 5.20 24,000 30,000 80% 30,000 20%

0044 4 INTRACRANIAL HEMORRHAGE 2.8556 2.6491 2.5837 10.51 24,000 30,000 80% 30,000 20%

0045 1 CVA & PRECEREBRAL OCCLUSION W INFARCT 0.7773 0.7211 0.7033 2.96 24,000 30,000 80% 30,000 20%

0045 2 CVA & PRECEREBRAL OCCLUSION W INFARCT 0.9760 0.9054 0.8830 3.96 24,000 30,000 80% 30,000 20%

0045 3 CVA & PRECEREBRAL OCCLUSION W INFARCT 1.6080 1.4917 1.4549 5.92 24,000 30,000 80% 30,000 20%

0045 4 CVA & PRECEREBRAL OCCLUSION W INFARCT 3.4067 3.1604 3.0823 10.65 24,000 30,000 80% 30,000 20%

0046 1 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT 0.6353 0.5894 0.5748 2.48 24,000 30,000 80% 30,000 20%

0046 2 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT 0.7729 0.7170 0.6993 3.26 24,000 30,000 80% 30,000 20%

0046 3 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT 1.2362 1.1468 1.1185 4.50 24,000 30,000 80% 30,000 20%

0046 4 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT 1.2450 1.1550 1.1265 9.68 24,000 30,000 80% 30,000 20%

0047 1 TRANSIENT ISCHEMIA 0.4760 0.4416 0.4307 2.01 24,000 30,000 80% 30,000 20%

0047 2 TRANSIENT ISCHEMIA 0.5699 0.5287 0.5156 2.60 24,000 30,000 80% 30,000 20%

0047 3 TRANSIENT ISCHEMIA 0.8221 0.7627 0.7439 3.60 24,000 30,000 80% 30,000 20%

0047 4 TRANSIENT ISCHEMIA 0.8462 0.7850 0.7656 7.60 24,000 30,000 80% 30,000 20%

0048 1 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS 0.5198 0.4822 0.4703 2.69 24,000 30,000 80% 30,000 20%

0048 2 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS 0.7230 0.6707 0.6541 3.79 24,000 30,000 80% 30,000 20%

0048 3 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS 1.1279 1.0464 1.0206 5.26 24,000 30,000 80% 30,000 20%

0048 4 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS 3.0211 2.8027 2.7335 11.36 24,000 30,000 80% 30,000 20%

0049 1 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1.2675 1.1759 1.1469 5.89 24,000 30,000 80% 30,000 20%

0049 2 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1.9177 1.7791 1.7352 6.39 24,000 30,000 80% 30,000 20%

0049 3 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 2.7241 2.5271 2.4647 10.09 24,000 30,000 80% 30,000 20%

0049 4 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 5.2843 4.9022 4.7811 15.69 24,000 30,000 80% 30,000 20%

0050 1 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 0.7912 0.7340 0.7159 3.95 24,000 30,000 80% 30,000 20%

0050 2 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 1.1938 1.1075 1.0801 5.17 24,000 30,000 80% 30,000 20%

0050 3 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 2.1458 1.9907 1.9415 8.75 24,000 30,000 80% 30,000 20%

0050 4 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 4.8947 4.5408 4.4286 16.90 24,000 30,000 80% 30,000 20%

0051 1 VIRAL MENINGITIS 0.5527 0.5127 0.5000 2.61 24,000 30,000 80% 30,000 20%

0051 2 VIRAL MENINGITIS 0.8017 0.7437 0.7253 3.70 24,000 30,000 80% 30,000 20%

0051 3 VIRAL MENINGITIS 1.3246 1.2288 1.1984 5.86 24,000 30,000 80% 30,000 20%

0051 4 VIRAL MENINGITIS 1.5253 1.4150 1.3800 12.10 24,000 30,000 80% 30,000 20%

0052 1 NONTRAUMATIC STUPOR & COMA 0.4310 0.3998 0.3899 1.92 24,000 30,000 80% 30,000 20%

0052 2 NONTRAUMATIC STUPOR & COMA 0.6096 0.5655 0.5515 3.04 24,000 30,000 80% 30,000 20%

0052 3 NONTRAUMATIC STUPOR & COMA 1.1339 1.0519 1.0259 5.10 24,000 30,000 80% 30,000 20%

0052 4 NONTRAUMATIC STUPOR & COMA 2.9456 2.7326 2.6651 9.60 24,000 30,000 80% 30,000 20%

0053 1 SEIZURE 0.4145 0.3845 0.3750 2.27 24,000 30,000 80% 30,000 20%

0053 2 SEIZURE 0.5275 0.4894 0.4773 2.88 24,000 30,000 80% 30,000 20%

0053 3 SEIZURE 0.9259 0.8590 0.8378 4.29 24,000 30,000 80% 30,000 20%

0053 4 SEIZURE 2.5847 2.3978 2.3386 9.17 24,000 30,000 80% 30,000 20%

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0054 1 MIGRAINE & OTHER HEADACHES 0.4251 0.3944 0.3847 2.36 24,000 30,000 80% 30,000 20%

0054 2 MIGRAINE & OTHER HEADACHES 0.5158 0.4785 0.4667 2.80 24,000 30,000 80% 30,000 20%

0054 3 MIGRAINE & OTHER HEADACHES 0.6891 0.6393 0.6235 3.66 24,000 30,000 80% 30,000 20%

0054 4 MIGRAINE & OTHER HEADACHES 0.7287 0.6760 0.6593 6.81 24,000 30,000 80% 30,000 20%

0055 1 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE 0.5534 0.5134 0.5007 2.28 24,000 30,000 80% 30,000 20%

0055 2 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE 0.8812 0.8175 0.7973 3.66 24,000 30,000 80% 30,000 20%

0055 3 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE 1.6559 1.5362 1.4983 5.32 24,000 30,000 80% 30,000 20%

0055 4 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE 3.9356 3.6511 3.5609 10.17 24,000 30,000 80% 30,000 20%

0056 1 BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA 0.4779 0.4433 0.4324 2.15 24,000 30,000 80% 30,000 20%

0056 2 BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA 0.8111 0.7525 0.7339 3.46 24,000 30,000 80% 30,000 20%

0056 3 BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA 1.6899 1.5677 1.5290 5.98 24,000 30,000 80% 30,000 20%

0056 4 BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA 2.1970 2.0382 1.9879 11.14 24,000 30,000 80% 30,000 20%

0057 1 CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA 0.3278 0.3041 0.2966 1.41 24,000 30,000 80% 30,000 20%

0057 2 CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA 0.5049 0.4684 0.4568 2.28 24,000 30,000 80% 30,000 20%

0057 3 CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA 1.0050 0.9323 0.9093 3.89 24,000 30,000 80% 30,000 20%

0057 4 CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA 1.3048 1.2105 1.1806 8.27 24,000 30,000 80% 30,000 20%

0058 1 OTHER DISORDERS OF NERVOUS SYSTEM 0.5094 0.4726 0.4609 2.69 24,000 30,000 80% 30,000 20%

0058 2 OTHER DISORDERS OF NERVOUS SYSTEM 0.7507 0.6964 0.6792 3.92 24,000 30,000 80% 30,000 20%

0058 3 OTHER DISORDERS OF NERVOUS SYSTEM 1.4047 1.3031 1.2709 5.74 24,000 30,000 80% 30,000 20%

0058 4 OTHER DISORDERS OF NERVOUS SYSTEM 3.3901 3.1450 3.0673 10.43 24,000 30,000 80% 30,000 20%

0070 1 ORBITAL PROCEDURES 0.6540 0.6067 0.5917 2.05 24,000 30,000 80% 30,000 20%

0070 2 ORBITAL PROCEDURES 1.0809 1.0028 0.9780 3.64 24,000 30,000 80% 30,000 20%

0070 3 ORBITAL PROCEDURES 2.5505 2.3661 2.3077 6.20 24,000 30,000 80% 30,000 20%

0070 4 ORBITAL PROCEDURES 2.6025 2.4143 2.3547 12.71 24,000 30,000 80% 30,000 20%

0073 1 EYE PROCEDURES EXCEPT ORBIT 0.6115 0.5673 0.5533 1.85 24,000 30,000 80% 30,000 20%

0073 2 EYE PROCEDURES EXCEPT ORBIT 0.7785 0.7222 0.7044 2.66 24,000 30,000 80% 30,000 20%

0073 3 EYE PROCEDURES EXCEPT ORBIT 1.1732 1.0884 1.0615 6.57 24,000 30,000 80% 30,000 20%

0073 4 EYE PROCEDURES EXCEPT ORBIT 1.4853 1.3779 1.3439 11.00 24,000 30,000 80% 30,000 20%

0080 1 ACUTE MAJOR EYE INFECTIONS 0.4744 0.4401 0.4292 2.71 24,000 30,000 80% 30,000 20%

0080 2 ACUTE MAJOR EYE INFECTIONS 0.6421 0.5957 0.5810 3.73 24,000 30,000 80% 30,000 20%

0080 3 ACUTE MAJOR EYE INFECTIONS 1.1426 1.0600 1.0338 6.54 24,000 30,000 80% 30,000 20%

0080 4 ACUTE MAJOR EYE INFECTIONS 1.2113 1.1237 1.0959 11.75 24,000 30,000 80% 30,000 20%

0082 1 EYE DISORDERS EXCEPT MAJOR INFECTIONS 0.4474 0.4151 0.4048 2.20 24,000 30,000 80% 30,000 20%

0082 2 EYE DISORDERS EXCEPT MAJOR INFECTIONS 0.5486 0.5089 0.4963 2.80 24,000 30,000 80% 30,000 20%

0082 3 EYE DISORDERS EXCEPT MAJOR INFECTIONS 0.9726 0.9023 0.8800 4.34 24,000 30,000 80% 30,000 20%

0082 4 EYE DISORDERS EXCEPT MAJOR INFECTIONS 1.1120 1.0316 1.0061 9.08 24,000 30,000 80% 30,000 20%

0089 1 MAJOR CRANIAL/FACIAL BONE PROCEDURES 1.2437 1.1538 1.1253 2.13 24,000 30,000 80% 30,000 20%

0089 2 MAJOR CRANIAL/FACIAL BONE PROCEDURES 1.8875 1.7510 1.7078 3.70 24,000 30,000 80% 30,000 20%

0089 3 MAJOR CRANIAL/FACIAL BONE PROCEDURES 3.1542 2.9262 2.8539 8.14 24,000 30,000 80% 30,000 20%

0089 4 MAJOR CRANIAL/FACIAL BONE PROCEDURES 10.6694 9.8980 9.6535 17.76 24,000 30,000 80% 30,000 20%

0090 1 MAJOR LARYNX & TRACHEA PROCEDURES 0.6893 0.6395 0.6237 2.48 24,000 30,000 80% 30,000 20%

0090 2 MAJOR LARYNX & TRACHEA PROCEDURES 2.2913 2.1256 2.0731 8.44 24,000 30,000 80% 30,000 20%

0090 3 MAJOR LARYNX & TRACHEA PROCEDURES 4.2119 3.9074 3.8109 13.55 24,000 30,000 80% 30,000 20%

0090 4 MAJOR LARYNX & TRACHEA PROCEDURES 5.1210 4.7508 4.6335 26.77 24,000 30,000 80% 30,000 20%

0091 1 OTHER MAJOR HEAD & NECK PROCEDURES 1.1993 1.1126 1.0851 3.14 24,000 30,000 80% 30,000 20%

0091 2 OTHER MAJOR HEAD & NECK PROCEDURES 2.8666 2.6593 2.5936 4.16 24,000 30,000 80% 30,000 20%

0091 3 OTHER MAJOR HEAD & NECK PROCEDURES 3.5306 3.2753 3.1944 8.94 24,000 30,000 80% 30,000 20%

0091 4 OTHER MAJOR HEAD & NECK PROCEDURES 3.5453 3.2890 3.2078 15.17 24,000 30,000 80% 30,000 20%

0092 1 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES 0.8879 0.8237 0.8034 1.99 24,000 30,000 80% 30,000 20%

0092 2 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES 1.1363 1.0541 1.0281 2.77 24,000 30,000 80% 30,000 20%

0092 3 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES 2.1040 1.9519 1.9037 5.41 24,000 30,000 80% 30,000 20%

0092 4 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES 2.4390 2.2627 2.2068 12.27 24,000 30,000 80% 30,000 20%

0093 1 SINUS & MASTOID PROCEDURES 0.7068 0.6557 0.6395 1.84 24,000 30,000 80% 30,000 20%

0093 2 SINUS & MASTOID PROCEDURES 1.1125 1.0321 1.0066 3.42 24,000 30,000 80% 30,000 20%

0093 3 SINUS & MASTOID PROCEDURES 2.2581 2.0948 2.0431 6.60 24,000 30,000 80% 30,000 20%

0093 4 SINUS & MASTOID PROCEDURES 2.3546 2.1844 2.1304 15.65 24,000 30,000 80% 30,000 20%

0095 1 CLEFT LIP & PALATE REPAIR 0.6043 0.5606 0.5468 1.39 24,000 30,000 80% 30,000 20%

0095 2 CLEFT LIP & PALATE REPAIR 0.7384 0.6850 0.6681 1.79 24,000 30,000 80% 30,000 20%

0095 3 CLEFT LIP & PALATE REPAIR 1.2117 1.1241 1.0963 2.85 24,000 30,000 80% 30,000 20%

0095 4 CLEFT LIP & PALATE REPAIR 1.3350 1.2385 1.2079 10.78 24,000 30,000 80% 30,000 20%

0097 1 TONSIL & ADENOID PROCEDURES 0.4281 0.3971 0.3873 1.55 24,000 30,000 80% 30,000 20%

0097 2 TONSIL & ADENOID PROCEDURES 0.6482 0.6013 0.5864 2.64 24,000 30,000 80% 30,000 20%

0097 3 TONSIL & ADENOID PROCEDURES 1.2450 1.1550 1.1265 5.07 24,000 30,000 80% 30,000 20%

0097 4 TONSIL & ADENOID PROCEDURES 1.4074 1.3056 1.2734 12.00 24,000 30,000 80% 30,000 20%

0098 1 OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES 0.6238 0.5787 0.5644 1.92 24,000 30,000 80% 30,000 20%

0098 2 OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES 0.8700 0.8071 0.7872 2.99 24,000 30,000 80% 30,000 20%

0098 3 OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES 1.8090 1.6782 1.6367 6.45 24,000 30,000 80% 30,000 20%

0098 4 OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES 3.9811 3.6933 3.6021 14.19 24,000 30,000 80% 30,000 20%

0110 1 EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES 0.5014 0.4651 0.4536 2.79 24,000 30,000 80% 30,000 20%

0110 2 EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES 0.7694 0.7138 0.6962 3.89 24,000 30,000 80% 30,000 20%

0110 3 EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES 1.5203 1.4104 1.3756 7.02 24,000 30,000 80% 30,000 20%

0110 4 EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES 3.7533 3.4819 3.3959 12.99 24,000 30,000 80% 30,000 20%

0111 1 VERTIGO & OTHER LABYRINTH DISORDERS 0.3893 0.3612 0.3523 1.99 24,000 30,000 80% 30,000 20%

0111 2 VERTIGO & OTHER LABYRINTH DISORDERS 0.4873 0.4521 0.4409 2.52 24,000 30,000 80% 30,000 20%

0111 3 VERTIGO & OTHER LABYRINTH DISORDERS 0.6980 0.6475 0.6315 3.33 24,000 30,000 80% 30,000 20%

0111 4 VERTIGO & OTHER LABYRINTH DISORDERS 0.7185 0.6666 0.6501 5.48 24,000 30,000 80% 30,000 20%

0113 1 INFECTIONS OF UPPER RESPIRATORY TRACT 0.3345 0.3103 0.3026 1.80 24,000 30,000 80% 30,000 20%

0113 2 INFECTIONS OF UPPER RESPIRATORY TRACT 0.4363 0.4048 0.3948 2.49 24,000 30,000 80% 30,000 20%

0113 3 INFECTIONS OF UPPER RESPIRATORY TRACT 0.6793 0.6302 0.6146 3.88 24,000 30,000 80% 30,000 20%

0113 4 INFECTIONS OF UPPER RESPIRATORY TRACT 1.8693 1.7341 1.6913 8.18 24,000 30,000 80% 30,000 20%

0114 1 DENTAL & ORAL DISEASES & INJURIES 0.4322 0.4010 0.3911 2.17 24,000 30,000 80% 30,000 20%

0114 2 DENTAL & ORAL DISEASES & INJURIES 0.5676 0.5266 0.5136 2.99 24,000 30,000 80% 30,000 20%

0114 3 DENTAL & ORAL DISEASES & INJURIES 1.0627 0.9859 0.9615 5.16 24,000 30,000 80% 30,000 20%

0114 4 DENTAL & ORAL DISEASES & INJURIES 1.1052 1.0253 1.0000 11.18 24,000 30,000 80% 30,000 20%

0115 1 OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 0.4038 0.3746 0.3653 2.16 24,000 30,000 80% 30,000 20%

0115 2 OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 0.5517 0.5118 0.4992 2.86 24,000 30,000 80% 30,000 20%

0115 3 OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 1.0958 1.0166 0.9915 4.66 24,000 30,000 80% 30,000 20%

0115 4 OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 2.4896 2.3096 2.2526 9.28 24,000 30,000 80% 30,000 20%

0120 1 MAJOR RESPIRATORY & CHEST PROCEDURES 1.6870 1.5650 1.5263 5.29 24,000 30,000 80% 30,000 20%

0120 2 MAJOR RESPIRATORY & CHEST PROCEDURES 2.1843 2.0264 1.9763 7.27 24,000 30,000 80% 30,000 20%

0120 3 MAJOR RESPIRATORY & CHEST PROCEDURES 3.4881 3.2359 3.1560 11.83 24,000 30,000 80% 30,000 20%

0120 4 MAJOR RESPIRATORY & CHEST PROCEDURES 6.8448 6.3499 6.1931 20.54 24,000 30,000 80% 30,000 20%

0121 1 OTHER RESPIRATORY & CHEST PROCEDURES 1.1716 1.0869 1.0601 3.49 24,000 30,000 80% 30,000 20%

0121 2 OTHER RESPIRATORY & CHEST PROCEDURES 1.6196 1.5025 1.4654 5.78 24,000 30,000 80% 30,000 20%

0121 3 OTHER RESPIRATORY & CHEST PROCEDURES 3.0606 2.8393 2.7692 10.53 24,000 30,000 80% 30,000 20%

0121 4 OTHER RESPIRATORY & CHEST PROCEDURES 6.3297 5.8721 5.7271 20.48 24,000 30,000 80% 30,000 20%

0130 1 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS 2.7231 2.5262 2.4638 11.04 24,000 30,000 80% 30,000 20%

0130 2 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS 2.9526 2.7391 2.6714 11.39 24,000 30,000 80% 30,000 20%

0130 3 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS 3.7505 3.4793 3.3934 13.32 24,000 30,000 80% 30,000 20%

0130 4 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS 5.6253 5.2186 5.0897 17.03 24,000 30,000 80% 30,000 20%

0131 1 CYSTIC FIBROSIS - PULMONARY DISEASE 1.2251 1.1365 1.1084 6.31 24,000 30,000 80% 30,000 20%

0131 2 CYSTIC FIBROSIS - PULMONARY DISEASE 1.3258 1.2299 1.1995 7.65 24,000 30,000 80% 30,000 20%

0131 3 CYSTIC FIBROSIS - PULMONARY DISEASE 1.6871 1.5651 1.5264 10.08 24,000 30,000 80% 30,000 20%

0131 4 CYSTIC FIBROSIS - PULMONARY DISEASE 2.6739 2.4806 2.4193 12.74 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0132 1 BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD 0.4974 0.4614 0.4500 2.54 24,000 30,000 80% 30,000 20%

0132 2 BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD 0.7669 0.7115 0.6939 3.42 24,000 30,000 80% 30,000 20%

0132 3 BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD 1.3807 1.2809 1.2493 6.65 24,000 30,000 80% 30,000 20%

0132 4 BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD 2.9287 2.7170 2.6499 10.67 24,000 30,000 80% 30,000 20%

0133 1 PULMONARY EDEMA & RESPIRATORY FAILURE 0.4794 0.4447 0.4337 2.25 24,000 30,000 80% 30,000 20%

0133 2 PULMONARY EDEMA & RESPIRATORY FAILURE 0.9228 0.8561 0.8350 4.17 24,000 30,000 80% 30,000 20%

0133 3 PULMONARY EDEMA & RESPIRATORY FAILURE 1.3476 1.2502 1.2193 5.48 24,000 30,000 80% 30,000 20%

0133 4 PULMONARY EDEMA & RESPIRATORY FAILURE 1.9759 1.8330 1.7877 7.46 24,000 30,000 80% 30,000 20%

0134 1 PULMONARY EMBOLISM 0.8234 0.7639 0.7450 3.99 24,000 30,000 80% 30,000 20%

0134 2 PULMONARY EMBOLISM 1.0404 0.9652 0.9414 4.86 24,000 30,000 80% 30,000 20%

0134 3 PULMONARY EMBOLISM 1.5709 1.4573 1.4213 6.58 24,000 30,000 80% 30,000 20%

0134 4 PULMONARY EMBOLISM 2.5937 2.4062 2.3468 9.30 24,000 30,000 80% 30,000 20%

0135 1 MAJOR CHEST & RESPIRATORY TRAUMA 0.5109 0.4740 0.4623 2.74 24,000 30,000 80% 30,000 20%

0135 2 MAJOR CHEST & RESPIRATORY TRAUMA 0.7478 0.6937 0.6766 3.62 24,000 30,000 80% 30,000 20%

0135 3 MAJOR CHEST & RESPIRATORY TRAUMA 1.2246 1.1361 1.1080 5.67 24,000 30,000 80% 30,000 20%

0135 4 MAJOR CHEST & RESPIRATORY TRAUMA 2.0659 1.9165 1.8692 7.79 24,000 30,000 80% 30,000 20%

0136 1 RESPIRATORY MALIGNANCY 0.6111 0.5669 0.5529 3.28 24,000 30,000 80% 30,000 20%

0136 2 RESPIRATORY MALIGNANCY 0.8975 0.8326 0.8120 4.46 24,000 30,000 80% 30,000 20%

0136 3 RESPIRATORY MALIGNANCY 1.6817 1.5601 1.5216 7.02 24,000 30,000 80% 30,000 20%

0136 4 RESPIRATORY MALIGNANCY 2.7157 2.5194 2.4572 10.15 24,000 30,000 80% 30,000 20%

0137 1 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 0.9369 0.8692 0.8477 4.70 24,000 30,000 80% 30,000 20%

0137 2 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 1.0684 0.9912 0.9667 5.57 24,000 30,000 80% 30,000 20%

0137 3 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 1.6140 1.4973 1.4603 7.74 24,000 30,000 80% 30,000 20%

0137 4 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 2.6718 2.4786 2.4174 10.46 24,000 30,000 80% 30,000 20%

0138 1 BRONCHIOLITIS & RSV PNEUMONIA 0.4193 0.3890 0.3794 2.36 24,000 30,000 80% 30,000 20%

0138 2 BRONCHIOLITIS & RSV PNEUMONIA 0.5832 0.5410 0.5276 3.05 24,000 30,000 80% 30,000 20%

0138 3 BRONCHIOLITIS & RSV PNEUMONIA 1.0499 0.9740 0.9499 5.22 24,000 30,000 80% 30,000 20%

0138 4 BRONCHIOLITIS & RSV PNEUMONIA 1.8715 1.7362 1.6933 8.03 24,000 30,000 80% 30,000 20%

0139 1 OTHER PNEUMONIA 0.4644 0.4308 0.4202 2.64 24,000 30,000 80% 30,000 20%

0139 2 OTHER PNEUMONIA 0.6697 0.6213 0.6060 3.87 24,000 30,000 80% 30,000 20%

0139 3 OTHER PNEUMONIA 1.1013 1.0217 0.9965 5.48 24,000 30,000 80% 30,000 20%

0139 4 OTHER PNEUMONIA 2.0992 1.9474 1.8993 8.60 24,000 30,000 80% 30,000 20%

0140 1 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 0.5565 0.5163 0.5035 3.21 24,000 30,000 80% 30,000 20%

0140 2 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 0.7185 0.6666 0.6501 3.87 24,000 30,000 80% 30,000 20%

0140 3 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 1.0477 0.9720 0.9480 5.10 24,000 30,000 80% 30,000 20%

0140 4 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 2.0550 1.9064 1.8593 8.37 24,000 30,000 80% 30,000 20%

0141 1 ASTHMA 0.4012 0.3722 0.3630 2.10 24,000 30,000 80% 30,000 20%

0141 2 ASTHMA 0.5320 0.4935 0.4813 2.93 24,000 30,000 80% 30,000 20%

0141 3 ASTHMA 0.7987 0.7410 0.7227 4.27 24,000 30,000 80% 30,000 20%

0141 4 ASTHMA 1.3465 1.2491 1.2182 5.40 24,000 30,000 80% 30,000 20%

0142 1 INTERSTITIAL LUNG DISEASE 0.6989 0.6484 0.6324 3.33 24,000 30,000 80% 30,000 20%

0142 2 INTERSTITIAL LUNG DISEASE 0.8825 0.8187 0.7985 4.36 24,000 30,000 80% 30,000 20%

0142 3 INTERSTITIAL LUNG DISEASE 1.2437 1.1538 1.1253 5.91 24,000 30,000 80% 30,000 20%

0142 4 INTERSTITIAL LUNG DISEASE 2.2024 2.0432 1.9927 9.69 24,000 30,000 80% 30,000 20%

0143 1 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES 0.4965 0.4606 0.4492 2.78 24,000 30,000 80% 30,000 20%

0143 2 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES 0.7395 0.6860 0.6691 3.70 24,000 30,000 80% 30,000 20%

0143 3 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES 1.1540 1.0706 1.0442 5.50 24,000 30,000 80% 30,000 20%

0143 4 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES 1.8672 1.7322 1.6894 7.92 24,000 30,000 80% 30,000 20%

0144 1 RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES 0.4094 0.3798 0.3704 2.08 24,000 30,000 80% 30,000 20%

0144 2 RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES 0.5252 0.4872 0.4752 2.90 24,000 30,000 80% 30,000 20%

0144 3 RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES 0.7617 0.7066 0.6891 3.99 24,000 30,000 80% 30,000 20%

0144 4 RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES 1.6397 1.5211 1.4835 6.67 24,000 30,000 80% 30,000 20%

0160 1 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 2.4477 2.2707 2.2146 3.90 24,000 30,000 80% 30,000 20%

0160 2 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 3.0613 2.8400 2.7699 5.62 24,000 30,000 80% 30,000 20%

0160 3 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 4.8499 4.4993 4.3882 8.36 24,000 30,000 80% 30,000 20%

0160 4 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 8.2341 7.6388 7.4501 18.95 24,000 30,000 80% 30,000 20%

0161 1 CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT 4.2601 3.9521 3.8545 1.88 24,000 30,000 80% 30,000 20%

0161 2 CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT 4.8166 4.4684 4.3580 2.72 24,000 30,000 80% 30,000 20%

0161 3 CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT 5.5248 5.1254 4.9988 4.95 24,000 30,000 80% 30,000 20%

0161 4 CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT 16.0248 14.8662 14.4990 17.18 24,000 30,000 80% 30,000 20%

0162 1 CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION 3.7742 3.5013 3.4148 8.33 24,000 30,000 80% 30,000 20%

0162 2 CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION 4.6041 4.2712 4.1657 9.07 24,000 30,000 80% 30,000 20%

0162 3 CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION 5.7530 5.3371 5.2053 12.58 24,000 30,000 80% 30,000 20%

0162 4 CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION 9.6869 8.9865 8.7645 20.89 24,000 30,000 80% 30,000 20%

0163 1 CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION 3.0741 2.8518 2.7814 5.46 24,000 30,000 80% 30,000 20%

0163 2 CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION 3.7898 3.5158 3.4290 6.40 24,000 30,000 80% 30,000 20%

0163 3 CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION 4.8640 4.5123 4.4008 8.77 24,000 30,000 80% 30,000 20%

0163 4 CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION 9.4834 8.7978 8.5805 17.51 24,000 30,000 80% 30,000 20%

0165 1 CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE 3.2051 2.9734 2.9000 6.64 24,000 30,000 80% 30,000 20%

0165 2 CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE 3.7268 3.4574 3.3720 8.02 24,000 30,000 80% 30,000 20%

0165 3 CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE 4.7570 4.4131 4.3041 10.13 24,000 30,000 80% 30,000 20%

0165 4 CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE 7.8371 7.2705 7.0909 16.10 24,000 30,000 80% 30,000 20%

0166 1 CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE 2.5199 2.3377 2.2800 4.94 24,000 30,000 80% 30,000 20%

0166 2 CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE 2.9355 2.7233 2.6560 6.00 24,000 30,000 80% 30,000 20%

0166 3 CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE 3.8260 3.5494 3.4617 8.12 24,000 30,000 80% 30,000 20%

0166 4 CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE 6.6809 6.1979 6.0448 14.79 24,000 30,000 80% 30,000 20%

0167 1 OTHER CARDIOTHORACIC PROCEDURES 2.1911 2.0327 1.9825 4.15 24,000 30,000 80% 30,000 20%

0167 2 OTHER CARDIOTHORACIC PROCEDURES 2.9474 2.7343 2.6668 5.40 24,000 30,000 80% 30,000 20%

0167 3 OTHER CARDIOTHORACIC PROCEDURES 3.8472 3.5690 3.4808 8.04 24,000 30,000 80% 30,000 20%

0167 4 OTHER CARDIOTHORACIC PROCEDURES 6.8094 6.3171 6.1611 15.94 24,000 30,000 80% 30,000 20%

0169 1 MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES 1.5520 1.4398 1.4042 4.37 24,000 30,000 80% 30,000 20%

0169 2 MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES 2.2916 2.1259 2.0734 5.56 24,000 30,000 80% 30,000 20%

0169 3 MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES 3.7797 3.5064 3.4198 8.30 24,000 30,000 80% 30,000 20%

0169 4 MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES 7.8927 7.3221 7.1412 17.56 24,000 30,000 80% 30,000 20%

0170 1 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK 2.8831 2.6747 2.6086 4.24 24,000 30,000 80% 30,000 20%

0170 2 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK 2.9390 2.7265 2.6592 5.28 24,000 30,000 80% 30,000 20%

0170 3 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK 3.8703 3.5905 3.5018 9.03 24,000 30,000 80% 30,000 20%

0170 4 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK 4.2249 3.9194 3.8226 15.07 24,000 30,000 80% 30,000 20%

0171 1 PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK 1.8163 1.6850 1.6434 2.19 24,000 30,000 80% 30,000 20%

0171 2 PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK 2.1860 2.0280 1.9779 3.57 24,000 30,000 80% 30,000 20%

0171 3 PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK 3.0260 2.8072 2.7379 6.27 24,000 30,000 80% 30,000 20%

0171 4 PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK 5.6835 5.2726 5.1424 12.15 24,000 30,000 80% 30,000 20%

0173 1 OTHER VASCULAR PROCEDURES 1.3744 1.2750 1.2435 2.23 24,000 30,000 80% 30,000 20%

0173 2 OTHER VASCULAR PROCEDURES 1.8946 1.7576 1.7142 3.59 24,000 30,000 80% 30,000 20%

0173 3 OTHER VASCULAR PROCEDURES 3.0630 2.8415 2.7713 8.00 24,000 30,000 80% 30,000 20%

0173 4 OTHER VASCULAR PROCEDURES 6.7428 6.2553 6.1008 17.65 24,000 30,000 80% 30,000 20%

0174 1 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI 2.0164 1.8706 1.8244 2.50 24,000 30,000 80% 30,000 20%

0174 2 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI 2.2102 2.0504 1.9998 3.11 24,000 30,000 80% 30,000 20%

0174 3 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI 2.8235 2.6194 2.5547 4.93 24,000 30,000 80% 30,000 20%

0174 4 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI 3.8908 3.6095 3.5203 8.81 24,000 30,000 80% 30,000 20%

0175 1 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI 1.4975 1.3892 1.3549 1.41 24,000 30,000 80% 30,000 20%

0175 2 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI 1.6180 1.5010 1.4639 1.95 24,000 30,000 80% 30,000 20%

0175 3 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI 2.1694 2.0126 1.9629 3.95 24,000 30,000 80% 30,000 20%

0175 4 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI 3.9956 3.7067 3.6151 9.26 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0176 1 CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT 1.2480 1.1578 1.1292 2.28 24,000 30,000 80% 30,000 20%

0176 2 CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT 2.8716 2.6640 2.5982 2.20 24,000 30,000 80% 30,000 20%

0176 3 CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT 3.0922 2.8686 2.7977 3.04 24,000 30,000 80% 30,000 20%

0176 4 CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT 3.1533 2.9253 2.8530 10.52 24,000 30,000 80% 30,000 20%

0177 1 CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT 1.0846 1.0062 0.9813 2.14 24,000 30,000 80% 30,000 20%

0177 2 CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT 1.5361 1.4250 1.3898 3.58 24,000 30,000 80% 30,000 20%

0177 3 CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT 2.5595 2.3744 2.3158 5.81 24,000 30,000 80% 30,000 20%

0177 4 CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT 4.9506 4.5927 4.4793 14.99 24,000 30,000 80% 30,000 20%

0180 1 OTHER CIRCULATORY SYSTEM PROCEDURES 0.9954 0.9234 0.9006 3.44 24,000 30,000 80% 30,000 20%

0180 2 OTHER CIRCULATORY SYSTEM PROCEDURES 1.6427 1.5239 1.4863 5.69 24,000 30,000 80% 30,000 20%

0180 3 OTHER CIRCULATORY SYSTEM PROCEDURES 2.7025 2.5071 2.4452 9.45 24,000 30,000 80% 30,000 20%

0180 4 OTHER CIRCULATORY SYSTEM PROCEDURES 5.6866 5.2755 5.1452 16.72 24,000 30,000 80% 30,000 20%

0190 1 ACUTE MYOCARDIAL INFARCTION 0.7857 0.7289 0.7109 2.13 24,000 30,000 80% 30,000 20%

0190 2 ACUTE MYOCARDIAL INFARCTION 0.9921 0.9204 0.8977 3.10 24,000 30,000 80% 30,000 20%

0190 3 ACUTE MYOCARDIAL INFARCTION 1.4659 1.3599 1.3263 4.94 24,000 30,000 80% 30,000 20%

0190 4 ACUTE MYOCARDIAL INFARCTION 2.7302 2.5328 2.4702 8.01 24,000 30,000 80% 30,000 20%

0191 1 CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE 0.8224 0.7629 0.7441 2.41 24,000 30,000 80% 30,000 20%

0191 2 CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE 1.0372 0.9622 0.9384 3.45 24,000 30,000 80% 30,000 20%

0191 3 CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE 1.4111 1.3091 1.2768 5.35 24,000 30,000 80% 30,000 20%

0191 4 CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE 3.6011 3.3407 3.2582 10.74 24,000 30,000 80% 30,000 20%

0192 1 CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE 0.6574 0.6099 0.5948 1.94 24,000 30,000 80% 30,000 20%

0192 2 CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE 0.7928 0.7355 0.7173 2.56 24,000 30,000 80% 30,000 20%

0192 3 CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE 1.1326 1.0507 1.0247 3.99 24,000 30,000 80% 30,000 20%

0192 4 CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE 2.1721 2.0151 1.9653 6.82 24,000 30,000 80% 30,000 20%

0193 1 ACUTE & SUBACUTE ENDOCARDITIS 0.9540 0.8850 0.8631 5.02 24,000 30,000 80% 30,000 20%

0193 2 ACUTE & SUBACUTE ENDOCARDITIS 1.3340 1.2376 1.2070 6.66 24,000 30,000 80% 30,000 20%

0193 3 ACUTE & SUBACUTE ENDOCARDITIS 2.4702 2.2916 2.2350 10.30 24,000 30,000 80% 30,000 20%

0193 4 ACUTE & SUBACUTE ENDOCARDITIS 4.3008 3.9899 3.8913 14.93 24,000 30,000 80% 30,000 20%

0194 1 HEART FAILURE 0.5393 0.5003 0.4879 2.89 24,000 30,000 80% 30,000 20%

0194 2 HEART FAILURE 0.7565 0.7018 0.6845 3.83 24,000 30,000 80% 30,000 20%

0194 3 HEART FAILURE 1.2476 1.1574 1.1288 5.59 24,000 30,000 80% 30,000 20%

0194 4 HEART FAILURE 2.9433 2.7305 2.6631 9.80 24,000 30,000 80% 30,000 20%

0196 1 CARDIAC ARREST 0.2703 0.2508 0.2446 1.56 24,000 30,000 80% 30,000 20%

0196 2 CARDIAC ARREST 0.4370 0.4054 0.3954 2.23 24,000 30,000 80% 30,000 20%

0196 3 CARDIAC ARREST 0.8748 0.8116 0.7916 2.22 24,000 30,000 80% 30,000 20%

0196 4 CARDIAC ARREST 2.2671 2.1032 2.0513 4.62 24,000 30,000 80% 30,000 20%

0197 1 PERIPHERAL & OTHER VASCULAR DISORDERS 0.5810 0.5390 0.5257 3.24 24,000 30,000 80% 30,000 20%

0197 2 PERIPHERAL & OTHER VASCULAR DISORDERS 0.7884 0.7314 0.7133 4.09 24,000 30,000 80% 30,000 20%

0197 3 PERIPHERAL & OTHER VASCULAR DISORDERS 1.2394 1.1498 1.1214 5.55 24,000 30,000 80% 30,000 20%

0197 4 PERIPHERAL & OTHER VASCULAR DISORDERS 2.5262 2.3436 2.2857 10.10 24,000 30,000 80% 30,000 20%

0198 1 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 0.3764 0.3492 0.3406 1.76 24,000 30,000 80% 30,000 20%

0198 2 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 0.4841 0.4491 0.4380 2.29 24,000 30,000 80% 30,000 20%

0198 3 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 0.6867 0.6371 0.6214 3.28 24,000 30,000 80% 30,000 20%

0198 4 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 1.3757 1.2762 1.2447 6.10 24,000 30,000 80% 30,000 20%

0199 1 HYPERTENSION 0.4028 0.3737 0.3645 1.98 24,000 30,000 80% 30,000 20%

0199 2 HYPERTENSION 0.5316 0.4932 0.4810 2.61 24,000 30,000 80% 30,000 20%

0199 3 HYPERTENSION 0.8563 0.7944 0.7748 3.77 24,000 30,000 80% 30,000 20%

0199 4 HYPERTENSION 2.5254 2.3428 2.2849 7.27 24,000 30,000 80% 30,000 20%

0200 1 CARDIAC STRUCTURAL & VALVULAR DISORDERS 0.4348 0.4034 0.3934 2.28 24,000 30,000 80% 30,000 20%

0200 2 CARDIAC STRUCTURAL & VALVULAR DISORDERS 0.6749 0.6261 0.6106 3.02 24,000 30,000 80% 30,000 20%

0200 3 CARDIAC STRUCTURAL & VALVULAR DISORDERS 1.0723 0.9948 0.9702 4.64 24,000 30,000 80% 30,000 20%

0200 4 CARDIAC STRUCTURAL & VALVULAR DISORDERS 4.4241 4.1042 4.0028 9.02 24,000 30,000 80% 30,000 20%

0201 1 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 0.4140 0.3841 0.3746 1.96 24,000 30,000 80% 30,000 20%

0201 2 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 0.5891 0.5465 0.5330 2.78 24,000 30,000 80% 30,000 20%

0201 3 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 0.9901 0.9185 0.8958 4.15 24,000 30,000 80% 30,000 20%

0201 4 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 2.4607 2.2828 2.2264 7.47 24,000 30,000 80% 30,000 20%

0203 1 CHEST PAIN 0.3360 0.3117 0.3040 1.43 24,000 30,000 80% 30,000 20%

0203 2 CHEST PAIN 0.4144 0.3844 0.3749 1.86 24,000 30,000 80% 30,000 20%

0203 3 CHEST PAIN 0.5885 0.5460 0.5325 2.76 24,000 30,000 80% 30,000 20%

0203 4 CHEST PAIN 1.4106 1.3086 1.2763 5.03 24,000 30,000 80% 30,000 20%

0204 1 SYNCOPE & COLLAPSE 0.4008 0.3718 0.3626 1.94 24,000 30,000 80% 30,000 20%

0204 2 SYNCOPE & COLLAPSE 0.5233 0.4855 0.4735 2.61 24,000 30,000 80% 30,000 20%

0204 3 SYNCOPE & COLLAPSE 0.7894 0.7323 0.7142 3.69 24,000 30,000 80% 30,000 20%

0204 4 SYNCOPE & COLLAPSE 1.6447 1.5258 1.4881 6.88 24,000 30,000 80% 30,000 20%

0205 1 CARDIOMYOPATHY 0.4736 0.4394 0.4285 2.29 24,000 30,000 80% 30,000 20%

0205 2 CARDIOMYOPATHY 0.6139 0.5695 0.5554 3.12 24,000 30,000 80% 30,000 20%

0205 3 CARDIOMYOPATHY 0.9942 0.9223 0.8995 4.68 24,000 30,000 80% 30,000 20%

0205 4 CARDIOMYOPATHY 1.1252 1.0438 1.0180 10.00 24,000 30,000 80% 30,000 20%

0206 1 MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE 0.5667 0.5257 0.5127 2.15 24,000 30,000 80% 30,000 20%

0206 2 MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE 0.7624 0.7073 0.6898 3.56 24,000 30,000 80% 30,000 20%

0206 3 MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE 1.3753 1.2759 1.2444 6.12 24,000 30,000 80% 30,000 20%

0206 4 MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE 2.8289 2.6244 2.5596 10.78 24,000 30,000 80% 30,000 20%

0207 1 OTHER CIRCULATORY SYSTEM DIAGNOSES 0.4580 0.4249 0.4144 2.32 24,000 30,000 80% 30,000 20%

0207 2 OTHER CIRCULATORY SYSTEM DIAGNOSES 0.6842 0.6347 0.6190 3.25 24,000 30,000 80% 30,000 20%

0207 3 OTHER CIRCULATORY SYSTEM DIAGNOSES 1.1555 1.0720 1.0455 4.79 24,000 30,000 80% 30,000 20%

0207 4 OTHER CIRCULATORY SYSTEM DIAGNOSES 2.4068 2.2328 2.1776 8.07 24,000 30,000 80% 30,000 20%

0220 1 MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 1.1649 1.0807 1.0540 4.27 24,000 30,000 80% 30,000 20%

0220 2 MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 1.9479 1.8071 1.7625 7.88 24,000 30,000 80% 30,000 20%

0220 3 MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 3.4872 3.2351 3.1552 12.72 24,000 30,000 80% 30,000 20%

0220 4 MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 7.9373 7.3634 7.1815 22.19 24,000 30,000 80% 30,000 20%

0221 1 MAJOR SMALL & LARGE BOWEL PROCEDURES 1.3241 1.2284 1.1981 5.22 24,000 30,000 80% 30,000 20%

0221 2 MAJOR SMALL & LARGE BOWEL PROCEDURES 1.7354 1.6099 1.5701 7.37 24,000 30,000 80% 30,000 20%

0221 3 MAJOR SMALL & LARGE BOWEL PROCEDURES 2.9676 2.7530 2.6850 12.10 24,000 30,000 80% 30,000 20%

0221 4 MAJOR SMALL & LARGE BOWEL PROCEDURES 6.3013 5.8457 5.7013 20.60 24,000 30,000 80% 30,000 20%

0222 1 OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 0.7585 0.7037 0.6863 2.23 24,000 30,000 80% 30,000 20%

0222 2 OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 1.0800 1.0019 0.9772 3.50 24,000 30,000 80% 30,000 20%

0222 3 OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 2.1995 2.0405 1.9901 8.94 24,000 30,000 80% 30,000 20%

0222 4 OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 6.6728 6.1904 6.0375 17.34 24,000 30,000 80% 30,000 20%

0223 1 OTHER SMALL & LARGE BOWEL PROCEDURES 1.0556 0.9793 0.9551 4.49 24,000 30,000 80% 30,000 20%

0223 2 OTHER SMALL & LARGE BOWEL PROCEDURES 1.4562 1.3509 1.3175 6.45 24,000 30,000 80% 30,000 20%

0223 3 OTHER SMALL & LARGE BOWEL PROCEDURES 2.2350 2.0734 2.0222 10.52 24,000 30,000 80% 30,000 20%

0223 4 OTHER SMALL & LARGE BOWEL PROCEDURES 6.9120 6.4123 6.2539 18.87 24,000 30,000 80% 30,000 20%

0224 1 PERITONEAL ADHESIOLYSIS 1.1319 1.0501 1.0242 5.14 24,000 30,000 80% 30,000 20%

0224 2 PERITONEAL ADHESIOLYSIS 1.5501 1.4380 1.4025 8.14 24,000 30,000 80% 30,000 20%

0224 3 PERITONEAL ADHESIOLYSIS 2.5762 2.3899 2.3309 11.51 24,000 30,000 80% 30,000 20%

0224 4 PERITONEAL ADHESIOLYSIS 5.2891 4.9067 4.7855 17.74 24,000 30,000 80% 30,000 20%

0225 1 APPENDECTOMY 0.6519 0.6048 0.5899 1.61 24,000 30,000 80% 30,000 20%

0225 2 APPENDECTOMY 0.9774 0.9067 0.8843 3.69 24,000 30,000 80% 30,000 20%

0225 3 APPENDECTOMY 1.8753 1.7397 1.6967 6.95 24,000 30,000 80% 30,000 20%

0225 4 APPENDECTOMY 4.2746 3.9655 3.8676 13.59 24,000 30,000 80% 30,000 20%

0226 1 ANAL PROCEDURES 0.5531 0.5131 0.5004 2.43 24,000 30,000 80% 30,000 20%

0226 2 ANAL PROCEDURES 0.7666 0.7112 0.6936 3.94 24,000 30,000 80% 30,000 20%

0226 3 ANAL PROCEDURES 1.5824 1.4680 1.4317 6.55 24,000 30,000 80% 30,000 20%

0226 4 ANAL PROCEDURES 3.6909 3.4240 3.3394 13.45 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0227 1 HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL 0.8370 0.7765 0.7573 2.65 24,000 30,000 80% 30,000 20%

0227 2 HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL 1.1251 1.0438 1.0180 4.06 24,000 30,000 80% 30,000 20%

0227 3 HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL 1.8867 1.7503 1.7071 7.51 24,000 30,000 80% 30,000 20%

0227 4 HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL 4.6017 4.2690 4.1636 14.01 24,000 30,000 80% 30,000 20%

0228 1 INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES 0.5854 0.5431 0.5297 1.86 24,000 30,000 80% 30,000 20%

0228 2 INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES 0.8357 0.7753 0.7562 3.20 24,000 30,000 80% 30,000 20%

0228 3 INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES 1.4351 1.3313 1.2984 5.94 24,000 30,000 80% 30,000 20%

0228 4 INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES 4.2735 3.9645 3.8666 13.36 24,000 30,000 80% 30,000 20%

0229 1 OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES 0.9631 0.8935 0.8714 3.53 24,000 30,000 80% 30,000 20%

0229 2 OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES 1.4946 1.3865 1.3523 5.63 24,000 30,000 80% 30,000 20%

0229 3 OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES 2.7867 2.5852 2.5213 10.20 24,000 30,000 80% 30,000 20%

0229 4 OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES 5.7295 5.3153 5.1840 17.81 24,000 30,000 80% 30,000 20%

0240 1 DIGESTIVE MALIGNANCY 0.5659 0.5250 0.5120 3.13 24,000 30,000 80% 30,000 20%

0240 2 DIGESTIVE MALIGNANCY 0.8755 0.8122 0.7921 4.29 24,000 30,000 80% 30,000 20%

0240 3 DIGESTIVE MALIGNANCY 1.6770 1.5558 1.5174 7.01 24,000 30,000 80% 30,000 20%

0240 4 DIGESTIVE MALIGNANCY 3.3510 3.1087 3.0319 11.91 24,000 30,000 80% 30,000 20%

0241 1 PEPTIC ULCER & GASTRITIS 0.4818 0.4470 0.4360 2.42 24,000 30,000 80% 30,000 20%

0241 2 PEPTIC ULCER & GASTRITIS 0.7080 0.6568 0.6406 3.26 24,000 30,000 80% 30,000 20%

0241 3 PEPTIC ULCER & GASTRITIS 1.1553 1.0718 1.0453 4.64 24,000 30,000 80% 30,000 20%

0241 4 PEPTIC ULCER & GASTRITIS 3.0180 2.7998 2.7306 8.67 24,000 30,000 80% 30,000 20%

0242 1 MAJOR ESOPHAGEAL DISORDERS 0.4859 0.4508 0.4397 2.20 24,000 30,000 80% 30,000 20%

0242 2 MAJOR ESOPHAGEAL DISORDERS 0.7676 0.7121 0.6945 3.15 24,000 30,000 80% 30,000 20%

0242 3 MAJOR ESOPHAGEAL DISORDERS 1.2152 1.1273 1.0995 4.56 24,000 30,000 80% 30,000 20%

0242 4 MAJOR ESOPHAGEAL DISORDERS 2.9155 2.7047 2.6379 9.57 24,000 30,000 80% 30,000 20%

0243 1 OTHER ESOPHAGEAL DISORDERS 0.4043 0.3751 0.3658 1.81 24,000 30,000 80% 30,000 20%

0243 2 OTHER ESOPHAGEAL DISORDERS 0.5742 0.5327 0.5195 2.72 24,000 30,000 80% 30,000 20%

0243 3 OTHER ESOPHAGEAL DISORDERS 1.0270 0.9527 0.9292 4.47 24,000 30,000 80% 30,000 20%

0243 4 OTHER ESOPHAGEAL DISORDERS 2.6543 2.4624 2.4016 8.87 24,000 30,000 80% 30,000 20%

0244 1 DIVERTICULITIS & DIVERTICULOSIS 0.5104 0.4735 0.4618 2.93 24,000 30,000 80% 30,000 20%

0244 2 DIVERTICULITIS & DIVERTICULOSIS 0.6768 0.6279 0.6124 3.63 24,000 30,000 80% 30,000 20%

0244 3 DIVERTICULITIS & DIVERTICULOSIS 1.1011 1.0215 0.9963 5.16 24,000 30,000 80% 30,000 20%

0244 4 DIVERTICULITIS & DIVERTICULOSIS 2.4782 2.2990 2.2422 9.67 24,000 30,000 80% 30,000 20%

0245 1 INFLAMMATORY BOWEL DISEASE 0.5988 0.5555 0.5418 3.34 24,000 30,000 80% 30,000 20%

0245 2 INFLAMMATORY BOWEL DISEASE 0.7694 0.7138 0.6962 4.24 24,000 30,000 80% 30,000 20%

0245 3 INFLAMMATORY BOWEL DISEASE 1.3189 1.2235 1.1933 6.36 24,000 30,000 80% 30,000 20%

0245 4 INFLAMMATORY BOWEL DISEASE 2.6364 2.4458 2.3854 11.82 24,000 30,000 80% 30,000 20%

0246 1 GASTROINTESTINAL VASCULAR INSUFFICIENCY 0.6011 0.5576 0.5438 3.16 24,000 30,000 80% 30,000 20%

0246 2 GASTROINTESTINAL VASCULAR INSUFFICIENCY 0.7932 0.7359 0.7177 4.14 24,000 30,000 80% 30,000 20%

0246 3 GASTROINTESTINAL VASCULAR INSUFFICIENCY 1.3723 1.2731 1.2417 6.37 24,000 30,000 80% 30,000 20%

0246 4 GASTROINTESTINAL VASCULAR INSUFFICIENCY 3.5028 3.2495 3.1692 9.96 24,000 30,000 80% 30,000 20%

0247 1 INTESTINAL OBSTRUCTION 0.4743 0.4400 0.4291 2.76 24,000 30,000 80% 30,000 20%

0247 2 INTESTINAL OBSTRUCTION 0.6558 0.6084 0.5934 3.71 24,000 30,000 80% 30,000 20%

0247 3 INTESTINAL OBSTRUCTION 1.0765 0.9987 0.9740 5.63 24,000 30,000 80% 30,000 20%

0247 4 INTESTINAL OBSTRUCTION 2.6996 2.5044 2.4425 10.83 24,000 30,000 80% 30,000 20%

0248 1 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 0.5288 0.4906 0.4785 3.15 24,000 30,000 80% 30,000 20%

0248 2 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 0.8033 0.7452 0.7268 4.72 24,000 30,000 80% 30,000 20%

0248 3 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 1.3422 1.2452 1.2144 6.87 24,000 30,000 80% 30,000 20%

0248 4 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 2.9811 2.7656 2.6973 11.96 24,000 30,000 80% 30,000 20%

0249 1 NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING 0.3396 0.3150 0.3072 1.95 24,000 30,000 80% 30,000 20%

0249 2 NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING 0.4590 0.4258 0.4153 2.73 24,000 30,000 80% 30,000 20%

0249 3 NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING 0.7221 0.6699 0.6534 3.99 24,000 30,000 80% 30,000 20%

0249 4 NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING 1.8895 1.7529 1.7096 7.20 24,000 30,000 80% 30,000 20%

0251 1 ABDOMINAL PAIN 0.3698 0.3431 0.3346 2.06 24,000 30,000 80% 30,000 20%

0251 2 ABDOMINAL PAIN 0.5228 0.4850 0.4730 2.84 24,000 30,000 80% 30,000 20%

0251 3 ABDOMINAL PAIN 0.8016 0.7436 0.7252 4.04 24,000 30,000 80% 30,000 20%

0251 4 ABDOMINAL PAIN 1.4449 1.3404 1.3073 6.63 24,000 30,000 80% 30,000 20%

0252 1 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE 0.5175 0.4801 0.4682 2.96 24,000 30,000 80% 30,000 20%

0252 2 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE 0.7165 0.6647 0.6483 3.94 24,000 30,000 80% 30,000 20%

0252 3 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE 1.2080 1.1207 1.0930 6.03 24,000 30,000 80% 30,000 20%

0252 4 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE 2.6912 2.4966 2.4349 11.23 24,000 30,000 80% 30,000 20%

0253 1 OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 0.5162 0.4789 0.4671 2.44 24,000 30,000 80% 30,000 20%

0253 2 OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 0.7212 0.6691 0.6526 3.29 24,000 30,000 80% 30,000 20%

0253 3 OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 1.1577 1.0740 1.0475 4.74 24,000 30,000 80% 30,000 20%

0253 4 OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 2.5495 2.3652 2.3068 8.55 24,000 30,000 80% 30,000 20%

0254 1 OTHER DIGESTIVE SYSTEM DIAGNOSES 0.4319 0.4007 0.3908 2.31 24,000 30,000 80% 30,000 20%

0254 2 OTHER DIGESTIVE SYSTEM DIAGNOSES 0.6733 0.6246 0.6092 3.41 24,000 30,000 80% 30,000 20%

0254 3 OTHER DIGESTIVE SYSTEM DIAGNOSES 1.0867 1.0081 0.9832 5.03 24,000 30,000 80% 30,000 20%

0254 4 OTHER DIGESTIVE SYSTEM DIAGNOSES 2.6606 2.4682 2.4072 9.57 24,000 30,000 80% 30,000 20%

0260 1 MAJOR PANCREAS, LIVER & SHUNT PROCEDURES 1.3597 1.2614 1.2302 4.70 24,000 30,000 80% 30,000 20%

0260 2 MAJOR PANCREAS, LIVER & SHUNT PROCEDURES 1.8259 1.6939 1.6521 6.19 24,000 30,000 80% 30,000 20%

0260 3 MAJOR PANCREAS, LIVER & SHUNT PROCEDURES 3.4022 3.1562 3.0782 11.56 24,000 30,000 80% 30,000 20%

0260 4 MAJOR PANCREAS, LIVER & SHUNT PROCEDURES 8.3787 7.7729 7.5809 22.92 24,000 30,000 80% 30,000 20%

0261 1 MAJOR BILIARY TRACT PROCEDURES 1.2585 1.1675 1.1387 4.96 24,000 30,000 80% 30,000 20%

0261 2 MAJOR BILIARY TRACT PROCEDURES 1.8811 1.7451 1.7020 7.60 24,000 30,000 80% 30,000 20%

0261 3 MAJOR BILIARY TRACT PROCEDURES 3.1829 2.9528 2.8799 11.53 24,000 30,000 80% 30,000 20%

0261 4 MAJOR BILIARY TRACT PROCEDURES 6.4517 5.9852 5.8374 17.83 24,000 30,000 80% 30,000 20%

0262 1 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 1.1538 1.0704 1.0440 4.17 24,000 30,000 80% 30,000 20%

0262 2 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 1.5222 1.4121 1.3772 5.78 24,000 30,000 80% 30,000 20%

0262 3 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 2.3567 2.1863 2.1323 9.09 24,000 30,000 80% 30,000 20%

0262 4 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 5.1003 4.7315 4.6146 15.64 24,000 30,000 80% 30,000 20%

0263 1 LAPAROSCOPIC CHOLECYSTECTOMY 0.7817 0.7252 0.7073 2.30 24,000 30,000 80% 30,000 20%

0263 2 LAPAROSCOPIC CHOLECYSTECTOMY 1.0933 1.0143 0.9892 3.58 24,000 30,000 80% 30,000 20%

0263 3 LAPAROSCOPIC CHOLECYSTECTOMY 1.6471 1.5280 1.4903 6.20 24,000 30,000 80% 30,000 20%

0263 4 LAPAROSCOPIC CHOLECYSTECTOMY 4.5499 4.2209 4.1166 12.55 24,000 30,000 80% 30,000 20%

0264 1 OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES 1.2195 1.1313 1.1034 4.84 24,000 30,000 80% 30,000 20%

0264 2 OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES 1.6765 1.5553 1.5169 6.20 24,000 30,000 80% 30,000 20%

0264 3 OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES 2.8704 2.6629 2.5971 11.26 24,000 30,000 80% 30,000 20%

0264 4 OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES 6.3439 5.8852 5.7398 20.21 24,000 30,000 80% 30,000 20%

0279 1 HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS 0.5514 0.5115 0.4989 2.79 24,000 30,000 80% 30,000 20%

0279 2 HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS 0.7615 0.7064 0.6890 3.66 24,000 30,000 80% 30,000 20%

0279 3 HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS 1.3411 1.2441 1.2134 5.70 24,000 30,000 80% 30,000 20%

0279 4 HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS 3.4005 3.1546 3.0767 10.31 24,000 30,000 80% 30,000 20%

0280 1 ALCOHOLIC LIVER DISEASE 0.5650 0.5242 0.5113 2.80 24,000 30,000 80% 30,000 20%

0280 2 ALCOHOLIC LIVER DISEASE 0.7215 0.6693 0.6528 3.46 24,000 30,000 80% 30,000 20%

0280 3 ALCOHOLIC LIVER DISEASE 1.2470 1.1568 1.1282 5.22 24,000 30,000 80% 30,000 20%

0280 4 ALCOHOLIC LIVER DISEASE 3.2805 3.0433 2.9681 10.10 24,000 30,000 80% 30,000 20%

0281 1 MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS 0.6026 0.5590 0.5452 3.34 24,000 30,000 80% 30,000 20%

0281 2 MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS 0.8696 0.8067 0.7868 4.34 24,000 30,000 80% 30,000 20%

0281 3 MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS 1.4149 1.3126 1.2802 6.37 24,000 30,000 80% 30,000 20%

0281 4 MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS 2.5961 2.4084 2.3489 10.28 24,000 30,000 80% 30,000 20%

0282 1 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 0.5736 0.5321 0.5190 3.24 24,000 30,000 80% 30,000 20%

0282 2 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 0.7752 0.7192 0.7014 4.08 24,000 30,000 80% 30,000 20%

0282 3 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 1.3879 1.2876 1.2558 6.15 24,000 30,000 80% 30,000 20%

0282 4 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 3.8622 3.5830 3.4945 12.24 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0283 1 OTHER DISORDERS OF THE LIVER 0.4485 0.4161 0.4058 2.44 24,000 30,000 80% 30,000 20%

0283 2 OTHER DISORDERS OF THE LIVER 0.7023 0.6515 0.6354 3.44 24,000 30,000 80% 30,000 20%

0283 3 OTHER DISORDERS OF THE LIVER 1.1711 1.0864 1.0596 4.98 24,000 30,000 80% 30,000 20%

0283 4 OTHER DISORDERS OF THE LIVER 3.1429 2.9157 2.8437 9.04 24,000 30,000 80% 30,000 20%

0284 1 DISORDERS OF GALLBLADDER & BILIARY TRACT 0.5271 0.4890 0.4769 2.39 24,000 30,000 80% 30,000 20%

0284 2 DISORDERS OF GALLBLADDER & BILIARY TRACT 0.7633 0.7081 0.6906 3.45 24,000 30,000 80% 30,000 20%

0284 3 DISORDERS OF GALLBLADDER & BILIARY TRACT 1.2391 1.1495 1.1211 5.35 24,000 30,000 80% 30,000 20%

0284 4 DISORDERS OF GALLBLADDER & BILIARY TRACT 2.8516 2.6454 2.5801 9.73 24,000 30,000 80% 30,000 20%

0301 1 HIP JOINT REPLACEMENT 1.9714 1.8289 1.7837 3.79 24,000 30,000 80% 30,000 20%

0301 2 HIP JOINT REPLACEMENT 2.0830 1.9324 1.8847 4.17 24,000 30,000 80% 30,000 20%

0301 3 HIP JOINT REPLACEMENT 2.5097 2.3282 2.2707 5.37 24,000 30,000 80% 30,000 20%

0301 4 HIP JOINT REPLACEMENT 5.5601 5.1581 5.0307 12.35 24,000 30,000 80% 30,000 20%

0302 1 KNEE JOINT REPLACEMENT 1.8204 1.6888 1.6471 3.20 24,000 30,000 80% 30,000 20%

0302 2 KNEE JOINT REPLACEMENT 2.0603 1.9113 1.8641 3.67 24,000 30,000 80% 30,000 20%

0302 3 KNEE JOINT REPLACEMENT 2.6037 2.4155 2.3558 5.32 24,000 30,000 80% 30,000 20%

0302 4 KNEE JOINT REPLACEMENT 5.3429 4.9566 4.8342 11.83 24,000 30,000 80% 30,000 20%

0303 1 DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK 3.6054 3.3447 3.2621 4.52 24,000 30,000 80% 30,000 20%

0303 2 DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK 4.0456 3.7531 3.6604 5.57 24,000 30,000 80% 30,000 20%

0303 3 DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK 6.1546 5.7096 5.5686 8.47 24,000 30,000 80% 30,000 20%

0303 4 DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK 9.7162 9.0137 8.7911 13.54 24,000 30,000 80% 30,000 20%

0304 1 DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 2.7316 2.5341 2.4715 3.17 24,000 30,000 80% 30,000 20%

0304 2 DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 3.1892 2.9586 2.8855 4.02 24,000 30,000 80% 30,000 20%

0304 3 DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 4.8094 4.4617 4.3515 7.10 24,000 30,000 80% 30,000 20%

0304 4 DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 8.9808 8.3315 8.1257 17.95 24,000 30,000 80% 30,000 20%

0305 1 AMPUTATION OF LOWER LIMB EXCEPT TOES 1.2430 1.1531 1.1246 4.85 24,000 30,000 80% 30,000 20%

0305 2 AMPUTATION OF LOWER LIMB EXCEPT TOES 1.8791 1.7432 1.7001 7.08 24,000 30,000 80% 30,000 20%

0305 3 AMPUTATION OF LOWER LIMB EXCEPT TOES 2.9323 2.7203 2.6531 10.67 24,000 30,000 80% 30,000 20%

0305 4 AMPUTATION OF LOWER LIMB EXCEPT TOES 5.7690 5.3519 5.2197 19.42 24,000 30,000 80% 30,000 20%

0308 1 HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT 1.1138 1.0333 1.0078 4.08 24,000 30,000 80% 30,000 20%

0308 2 HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT 1.5181 1.4083 1.3735 5.00 24,000 30,000 80% 30,000 20%

0308 3 HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT 2.3074 2.1406 2.0877 6.88 24,000 30,000 80% 30,000 20%

0308 4 HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT 4.4010 4.0828 3.9820 12.50 24,000 30,000 80% 30,000 20%

0309 1 HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT 1.0317 0.9571 0.9335 2.74 24,000 30,000 80% 30,000 20%

0309 2 HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT 1.5829 1.4685 1.4322 5.06 24,000 30,000 80% 30,000 20%

0309 3 HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT 2.9816 2.7660 2.6977 9.35 24,000 30,000 80% 30,000 20%

0309 4 HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT 6.8966 6.3980 6.2400 19.04 24,000 30,000 80% 30,000 20%

0310 1 INTERVERTEBRAL DISC EXCISION & DECOMPRESSION 0.6798 0.6307 0.6151 1.64 24,000 30,000 80% 30,000 20%

0310 2 INTERVERTEBRAL DISC EXCISION & DECOMPRESSION 0.9764 0.9058 0.8834 2.35 24,000 30,000 80% 30,000 20%

0310 3 INTERVERTEBRAL DISC EXCISION & DECOMPRESSION 1.9697 1.8273 1.7822 4.73 24,000 30,000 80% 30,000 20%

0310 4 INTERVERTEBRAL DISC EXCISION & DECOMPRESSION 5.3500 4.9632 4.8406 14.19 24,000 30,000 80% 30,000 20%

0312 1 SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES 1.2608 1.1696 1.1407 4.67 24,000 30,000 80% 30,000 20%

0312 2 SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES 2.0627 1.9136 1.8663 8.40 24,000 30,000 80% 30,000 20%

0312 3 SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES 4.7617 4.4174 4.3083 17.45 24,000 30,000 80% 30,000 20%

0312 4 SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES 12.3781 11.4832 11.1996 31.79 24,000 30,000 80% 30,000 20%

0313 1 KNEE & LOWER LEG PROCEDURES EXCEPT FOOT 0.9050 0.8396 0.8189 2.44 24,000 30,000 80% 30,000 20%

0313 2 KNEE & LOWER LEG PROCEDURES EXCEPT FOOT 1.3972 1.2962 1.2642 4.13 24,000 30,000 80% 30,000 20%

0313 3 KNEE & LOWER LEG PROCEDURES EXCEPT FOOT 2.5046 2.3235 2.2661 7.36 24,000 30,000 80% 30,000 20%

0313 4 KNEE & LOWER LEG PROCEDURES EXCEPT FOOT 6.2574 5.8050 5.6616 16.19 24,000 30,000 80% 30,000 20%

0314 1 FOOT & TOE PROCEDURES 0.8471 0.7859 0.7665 2.25 24,000 30,000 80% 30,000 20%

0314 2 FOOT & TOE PROCEDURES 1.1771 1.0920 1.0650 4.65 24,000 30,000 80% 30,000 20%

0314 3 FOOT & TOE PROCEDURES 1.8258 1.6938 1.6520 7.81 24,000 30,000 80% 30,000 20%

0314 4 FOOT & TOE PROCEDURES 3.5846 3.3254 3.2433 14.86 24,000 30,000 80% 30,000 20%

0315 1 SHOULDER, UPPER ARM & FOREARM PROCEDURES 0.6880 0.6383 0.6225 1.68 24,000 30,000 80% 30,000 20%

0315 2 SHOULDER, UPPER ARM & FOREARM PROCEDURES 1.1288 1.0472 1.0213 2.69 24,000 30,000 80% 30,000 20%

0315 3 SHOULDER, UPPER ARM & FOREARM PROCEDURES 2.3150 2.1476 2.0946 6.24 24,000 30,000 80% 30,000 20%

0315 4 SHOULDER, UPPER ARM & FOREARM PROCEDURES 5.3619 4.9742 4.8513 14.08 24,000 30,000 80% 30,000 20%

0316 1 HAND & WRIST PROCEDURES 0.6017 0.5582 0.5444 1.99 24,000 30,000 80% 30,000 20%

0316 2 HAND & WRIST PROCEDURES 0.9397 0.8718 0.8503 3.65 24,000 30,000 80% 30,000 20%

0316 3 HAND & WRIST PROCEDURES 2.3885 2.2158 2.1611 6.63 24,000 30,000 80% 30,000 20%

0316 4 HAND & WRIST PROCEDURES 3.2125 2.9802 2.9066 12.13 24,000 30,000 80% 30,000 20%

0317 1 TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES 0.7151 0.6634 0.6470 2.72 24,000 30,000 80% 30,000 20%

0317 2 TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES 1.2522 1.1617 1.1330 5.04 24,000 30,000 80% 30,000 20%

0317 3 TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES 2.4803 2.3010 2.2442 9.93 24,000 30,000 80% 30,000 20%

0317 4 TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES 6.4481 5.9819 5.8341 19.75 24,000 30,000 80% 30,000 20%

0320 1 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES 0.8020 0.7440 0.7256 2.03 24,000 30,000 80% 30,000 20%

0320 2 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES 1.4386 1.3346 1.3016 4.47 24,000 30,000 80% 30,000 20%

0320 3 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES 2.6150 2.4259 2.3660 8.73 24,000 30,000 80% 30,000 20%

0320 4 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES 7.1594 6.6418 6.4777 17.48 24,000 30,000 80% 30,000 20%

0321 1 CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP 1.3945 1.2937 1.2617 1.59 24,000 30,000 80% 30,000 20%

0321 2 CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP 1.8953 1.7583 1.7149 2.71 24,000 30,000 80% 30,000 20%

0321 3 CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP 3.8021 3.5272 3.4401 7.45 24,000 30,000 80% 30,000 20%

0321 4 CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP 6.3717 5.9110 5.7650 17.09 24,000 30,000 80% 30,000 20%

0340 1 FRACTURE OF FEMUR 0.5458 0.5063 0.4938 2.76 24,000 30,000 80% 30,000 20%

0340 2 FRACTURE OF FEMUR 0.7332 0.6802 0.6634 3.54 24,000 30,000 80% 30,000 20%

0340 3 FRACTURE OF FEMUR 1.3271 1.2312 1.2008 4.89 24,000 30,000 80% 30,000 20%

0340 4 FRACTURE OF FEMUR 2.4763 2.2973 2.2406 7.60 24,000 30,000 80% 30,000 20%

0341 1 FRACTURE OF PELVIS OR DISLOCATION OF HIP 0.5025 0.4662 0.4547 3.03 24,000 30,000 80% 30,000 20%

0341 2 FRACTURE OF PELVIS OR DISLOCATION OF HIP 0.7035 0.6526 0.6365 3.77 24,000 30,000 80% 30,000 20%

0341 3 FRACTURE OF PELVIS OR DISLOCATION OF HIP 1.0053 0.9326 0.9096 4.77 24,000 30,000 80% 30,000 20%

0341 4 FRACTURE OF PELVIS OR DISLOCATION OF HIP 1.0575 0.9810 0.9568 9.76 24,000 30,000 80% 30,000 20%

0342 1 FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK 0.3852 0.3574 0.3486 2.00 24,000 30,000 80% 30,000 20%

0342 2 FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK 0.6215 0.5766 0.5624 3.35 24,000 30,000 80% 30,000 20%

0342 3 FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK 1.0804 1.0023 0.9775 4.86 24,000 30,000 80% 30,000 20%

0342 4 FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK 2.2882 2.1228 2.0704 9.69 24,000 30,000 80% 30,000 20%

0343 1 MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG 0.6902 0.6403 0.6245 3.63 24,000 30,000 80% 30,000 20%

0343 2 MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG 0.9747 0.9042 0.8819 4.76 24,000 30,000 80% 30,000 20%

0343 3 MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG 1.8536 1.7196 1.6771 7.66 24,000 30,000 80% 30,000 20%

0343 4 MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG 3.8789 3.5985 3.5096 13.21 24,000 30,000 80% 30,000 20%

0344 1 OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS 0.7789 0.7226 0.7048 4.16 24,000 30,000 80% 30,000 20%

0344 2 OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS 1.1346 1.0526 1.0266 5.87 24,000 30,000 80% 30,000 20%

0344 3 OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS 1.7536 1.6268 1.5866 8.50 24,000 30,000 80% 30,000 20%

0344 4 OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS 3.6289 3.3665 3.2833 13.99 24,000 30,000 80% 30,000 20%

0346 1 CONNECTIVE TISSUE DISORDERS 0.5863 0.5439 0.5305 2.98 24,000 30,000 80% 30,000 20%

0346 2 CONNECTIVE TISSUE DISORDERS 0.8136 0.7548 0.7362 4.26 24,000 30,000 80% 30,000 20%

0346 3 CONNECTIVE TISSUE DISORDERS 1.4679 1.3618 1.3282 6.42 24,000 30,000 80% 30,000 20%

0346 4 CONNECTIVE TISSUE DISORDERS 4.2342 3.9281 3.8311 13.37 24,000 30,000 80% 30,000 20%

0347 1 OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES 0.5095 0.4727 0.4610 2.89 24,000 30,000 80% 30,000 20%

0347 2 OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES 0.7165 0.6647 0.6483 3.88 24,000 30,000 80% 30,000 20%

0347 3 OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES 1.2411 1.1514 1.1230 5.37 24,000 30,000 80% 30,000 20%

0347 4 OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES 2.5795 2.3930 2.3339 11.06 24,000 30,000 80% 30,000 20%

0349 1 MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE 0.4861 0.4510 0.4399 2.07 24,000 30,000 80% 30,000 20%

0349 2 MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE 0.8589 0.7968 0.7771 4.14 24,000 30,000 80% 30,000 20%

0349 3 MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE 1.3303 1.2341 1.2036 6.62 24,000 30,000 80% 30,000 20%

0349 4 MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE 2.4197 2.2448 2.1894 10.91 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0351 1 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES 0.4212 0.3907 0.3810 2.41 24,000 30,000 80% 30,000 20%

0351 2 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES 0.5867 0.5443 0.5309 3.40 24,000 30,000 80% 30,000 20%

0351 3 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES 1.0342 0.9594 0.9357 4.76 24,000 30,000 80% 30,000 20%

0351 4 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES 3.0472 2.8269 2.7571 9.51 24,000 30,000 80% 30,000 20%

0361 1 SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES 1.0841 1.0057 0.9809 3.47 24,000 30,000 80% 30,000 20%

0361 2 SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES 1.8015 1.6713 1.6300 7.26 24,000 30,000 80% 30,000 20%

0361 3 SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES 3.5705 3.3124 3.2306 14.03 24,000 30,000 80% 30,000 20%

0361 4 SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES 8.2608 7.6635 7.4742 24.23 24,000 30,000 80% 30,000 20%

0362 1 MASTECTOMY PROCEDURES 0.9247 0.8578 0.8366 1.74 24,000 30,000 80% 30,000 20%

0362 2 MASTECTOMY PROCEDURES 1.3204 1.2249 1.1946 2.22 24,000 30,000 80% 30,000 20%

0362 3 MASTECTOMY PROCEDURES 1.7336 1.6083 1.5686 5.60 24,000 30,000 80% 30,000 20%

0362 4 MASTECTOMY PROCEDURES 3.0968 2.8729 2.8019 11.83 24,000 30,000 80% 30,000 20%

0363 1 BREAST PROCEDURES EXCEPT MASTECTOMY 0.7097 0.6584 0.6421 1.62 24,000 30,000 80% 30,000 20%

0363 2 BREAST PROCEDURES EXCEPT MASTECTOMY 1.1585 1.0747 1.0482 2.82 24,000 30,000 80% 30,000 20%

0363 3 BREAST PROCEDURES EXCEPT MASTECTOMY 2.0127 1.8672 1.8211 6.05 24,000 30,000 80% 30,000 20%

0363 4 BREAST PROCEDURES EXCEPT MASTECTOMY 2.0314 1.8845 1.8380 15.24 24,000 30,000 80% 30,000 20%

0364 1 OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES 0.6973 0.6469 0.6309 2.54 24,000 30,000 80% 30,000 20%

0364 2 OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES 1.1036 1.0238 0.9985 4.82 24,000 30,000 80% 30,000 20%

0364 3 OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES 2.3131 2.1459 2.0929 9.08 24,000 30,000 80% 30,000 20%

0364 4 OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES 5.1497 4.7774 4.6594 17.09 24,000 30,000 80% 30,000 20%

0380 1 SKIN ULCERS 0.6572 0.6097 0.5946 3.96 24,000 30,000 80% 30,000 20%

0380 2 SKIN ULCERS 0.8366 0.7761 0.7569 5.04 24,000 30,000 80% 30,000 20%

0380 3 SKIN ULCERS 1.2972 1.2034 1.1737 7.15 24,000 30,000 80% 30,000 20%

0380 4 SKIN ULCERS 2.8692 2.6618 2.5961 12.78 24,000 30,000 80% 30,000 20%

0381 1 MAJOR SKIN DISORDERS 0.5073 0.4706 0.4590 2.76 24,000 30,000 80% 30,000 20%

0381 2 MAJOR SKIN DISORDERS 0.7665 0.7111 0.6935 4.15 24,000 30,000 80% 30,000 20%

0381 3 MAJOR SKIN DISORDERS 1.2782 1.1858 1.1565 6.44 24,000 30,000 80% 30,000 20%

0381 4 MAJOR SKIN DISORDERS 4.5435 4.2150 4.1109 12.53 24,000 30,000 80% 30,000 20%

0382 1 MALIGNANT BREAST DISORDERS 0.3212 0.2980 0.2906 2.42 24,000 30,000 80% 30,000 20%

0382 2 MALIGNANT BREAST DISORDERS 0.6957 0.6454 0.6295 3.99 24,000 30,000 80% 30,000 20%

0382 3 MALIGNANT BREAST DISORDERS 1.6362 1.5179 1.4804 6.71 24,000 30,000 80% 30,000 20%

0382 4 MALIGNANT BREAST DISORDERS 1.7420 1.6161 1.5762 10.73 24,000 30,000 80% 30,000 20%

0383 1 CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS 0.4613 0.4279 0.4173 2.99 24,000 30,000 80% 30,000 20%

0383 2 CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS 0.6582 0.6106 0.5955 4.16 24,000 30,000 80% 30,000 20%

0383 3 CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS 1.1066 1.0266 1.0012 5.83 24,000 30,000 80% 30,000 20%

0383 4 CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS 2.8061 2.6032 2.5389 10.15 24,000 30,000 80% 30,000 20%

0384 1 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE 0.3654 0.3390 0.3306 1.78 24,000 30,000 80% 30,000 20%

0384 2 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE 0.5242 0.4863 0.4743 2.92 24,000 30,000 80% 30,000 20%

0384 3 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE 0.9423 0.8742 0.8526 4.40 24,000 30,000 80% 30,000 20%

0384 4 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE 2.6305 2.4403 2.3800 8.89 24,000 30,000 80% 30,000 20%

0385 1 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS 0.4037 0.3745 0.3652 2.35 24,000 30,000 80% 30,000 20%

0385 2 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS 0.5664 0.5254 0.5124 3.37 24,000 30,000 80% 30,000 20%

0385 3 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS 0.9947 0.9228 0.9000 5.28 24,000 30,000 80% 30,000 20%

0385 4 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS 2.1522 1.9966 1.9473 10.06 24,000 30,000 80% 30,000 20%

0401 1 PITUITARY & ADRENAL PROCEDURES 1.1479 1.0649 1.0386 3.15 24,000 30,000 80% 30,000 20%

0401 2 PITUITARY & ADRENAL PROCEDURES 1.6965 1.5738 1.5349 4.44 24,000 30,000 80% 30,000 20%

0401 3 PITUITARY & ADRENAL PROCEDURES 3.4423 3.1934 3.1145 8.65 24,000 30,000 80% 30,000 20%

0401 4 PITUITARY & ADRENAL PROCEDURES 7.7556 7.1949 7.0172 20.16 24,000 30,000 80% 30,000 20%

0403 1 PROCEDURES FOR OBESITY 1.1201 1.0391 1.0134 1.87 24,000 30,000 80% 30,000 20%

0403 2 PROCEDURES FOR OBESITY 1.2442 1.1542 1.1257 2.23 24,000 30,000 80% 30,000 20%

0403 3 PROCEDURES FOR OBESITY 1.8816 1.7456 1.7025 4.94 24,000 30,000 80% 30,000 20%

0403 4 PROCEDURES FOR OBESITY 7.1517 6.6346 6.4707 19.83 24,000 30,000 80% 30,000 20%

0404 1 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES 0.5772 0.5355 0.5223 1.31 24,000 30,000 80% 30,000 20%

0404 2 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES 0.7768 0.7206 0.7028 2.14 24,000 30,000 80% 30,000 20%

0404 3 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES 2.1874 2.0293 1.9792 5.86 24,000 30,000 80% 30,000 20%

0404 4 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES 2.7043 2.5088 2.4468 16.08 24,000 30,000 80% 30,000 20%

0405 1 OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS 0.9407 0.8727 0.8511 2.95 24,000 30,000 80% 30,000 20%

0405 2 OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS 1.6172 1.5003 1.4632 5.37 24,000 30,000 80% 30,000 20%

0405 3 OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS 2.9458 2.7328 2.6653 9.32 24,000 30,000 80% 30,000 20%

0405 4 OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS 7.2499 6.7257 6.5596 23.05 24,000 30,000 80% 30,000 20%

0420 1 DIABETES 0.4105 0.3808 0.3714 2.54 24,000 30,000 80% 30,000 20%

0420 2 DIABETES 0.5852 0.5429 0.5295 2.73 24,000 30,000 80% 30,000 20%

0420 3 DIABETES 0.8934 0.8288 0.8083 4.02 24,000 30,000 80% 30,000 20%

0420 4 DIABETES 2.3763 2.2045 2.1500 8.13 24,000 30,000 80% 30,000 20%

0421 1 MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS 0.5081 0.4714 0.4598 3.10 24,000 30,000 80% 30,000 20%

0421 2 MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS 0.7239 0.6716 0.6550 4.30 24,000 30,000 80% 30,000 20%

0421 3 MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS 1.2364 1.1470 1.1187 6.09 24,000 30,000 80% 30,000 20%

0421 4 MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS 3.3312 3.0904 3.0141 11.78 24,000 30,000 80% 30,000 20%

0422 1 HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS 0.3194 0.2963 0.2890 1.97 24,000 30,000 80% 30,000 20%

0422 2 HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS 0.5284 0.4902 0.4781 3.06 24,000 30,000 80% 30,000 20%

0422 3 HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS 0.9169 0.8506 0.8296 4.49 24,000 30,000 80% 30,000 20%

0422 4 HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS 2.7629 2.5631 2.4998 8.55 24,000 30,000 80% 30,000 20%

0423 1 INBORN ERRORS OF METABOLISM 0.4674 0.4336 0.4229 2.26 24,000 30,000 80% 30,000 20%

0423 2 INBORN ERRORS OF METABOLISM 0.7255 0.6730 0.6564 3.61 24,000 30,000 80% 30,000 20%

0423 3 INBORN ERRORS OF METABOLISM 1.3588 1.2606 1.2295 5.37 24,000 30,000 80% 30,000 20%

0423 4 INBORN ERRORS OF METABOLISM 7.4495 6.9109 6.7402 13.66 24,000 30,000 80% 30,000 20%

0424 1 OTHER ENDOCRINE DISORDERS 0.4556 0.4227 0.4123 2.32 24,000 30,000 80% 30,000 20%

0424 2 OTHER ENDOCRINE DISORDERS 0.7097 0.6584 0.6421 3.92 24,000 30,000 80% 30,000 20%

0424 3 OTHER ENDOCRINE DISORDERS 1.1920 1.1058 1.0785 5.70 24,000 30,000 80% 30,000 20%

0424 4 OTHER ENDOCRINE DISORDERS 2.7583 2.5589 2.4957 10.60 24,000 30,000 80% 30,000 20%

0425 1 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 0.3967 0.3680 0.3589 2.36 24,000 30,000 80% 30,000 20%

0425 2 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 0.5587 0.5183 0.5055 2.96 24,000 30,000 80% 30,000 20%

0425 3 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 0.8795 0.8159 0.7957 4.21 24,000 30,000 80% 30,000 20%

0425 4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 2.5356 2.3523 2.2942 8.54 24,000 30,000 80% 30,000 20%

0440 1 KIDNEY TRANSPLANT 5.8810 5.4558 5.3210 4.89 24,000 30,000 100% 30,000 20%

0440 2 KIDNEY TRANSPLANT 6.2170 5.7675 5.6250 5.79 24,000 30,000 100% 30,000 20%

0440 3 KIDNEY TRANSPLANT 7.3192 6.7900 6.6223 8.44 24,000 30,000 100% 30,000 20%

0440 4 KIDNEY TRANSPLANT 10.3421 9.5944 9.3574 17.01 24,000 30,000 100% 30,000 20%

0441 1 MAJOR BLADDER PROCEDURES 1.1951 1.1087 1.0813 4.74 24,000 30,000 80% 30,000 20%

0441 2 MAJOR BLADDER PROCEDURES 2.1229 1.9694 1.9208 7.07 24,000 30,000 80% 30,000 20%

0441 3 MAJOR BLADDER PROCEDURES 3.0496 2.8291 2.7592 9.99 24,000 30,000 80% 30,000 20%

0441 4 MAJOR BLADDER PROCEDURES 7.2566 6.7319 6.5656 21.39 24,000 30,000 80% 30,000 20%

0442 1 KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY 1.1581 1.0744 1.0479 3.57 24,000 30,000 80% 30,000 20%

0442 2 KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY 1.4119 1.3098 1.2774 4.53 24,000 30,000 80% 30,000 20%

0442 3 KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY 2.6054 2.4170 2.3573 7.77 24,000 30,000 80% 30,000 20%

0442 4 KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY 5.9266 5.4981 5.3623 14.20 24,000 30,000 80% 30,000 20%

0443 1 KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY 0.9249 0.8580 0.8368 2.65 24,000 30,000 80% 30,000 20%

0443 2 KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY 1.1013 1.0217 0.9965 3.58 24,000 30,000 80% 30,000 20%

0443 3 KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY 2.3428 2.1734 2.1197 8.55 24,000 30,000 80% 30,000 20%

0443 4 KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY 5.7076 5.2949 5.1641 16.35 24,000 30,000 80% 30,000 20%

0444 1 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 0.8240 0.7644 0.7455 2.25 24,000 30,000 80% 30,000 20%

0444 2 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 1.4658 1.3598 1.3262 4.05 24,000 30,000 80% 30,000 20%

0444 3 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 2.7758 2.5751 2.5115 8.70 24,000 30,000 80% 30,000 20%

0444 4 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 6.4406 5.9749 5.8273 16.70 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0445 1 OTHER BLADDER PROCEDURES 0.6372 0.5911 0.5765 1.91 24,000 30,000 80% 30,000 20%

0445 2 OTHER BLADDER PROCEDURES 1.1404 1.0579 1.0318 2.87 24,000 30,000 80% 30,000 20%

0445 3 OTHER BLADDER PROCEDURES 1.8054 1.6749 1.6335 7.73 24,000 30,000 80% 30,000 20%

0445 4 OTHER BLADDER PROCEDURES 2.3616 2.1909 2.1368 16.91 24,000 30,000 80% 30,000 20%

0446 1 URETHRAL & TRANSURETHRAL PROCEDURES 0.5796 0.5377 0.5244 1.72 24,000 30,000 80% 30,000 20%

0446 2 URETHRAL & TRANSURETHRAL PROCEDURES 0.7305 0.6777 0.6610 2.47 24,000 30,000 80% 30,000 20%

0446 3 URETHRAL & TRANSURETHRAL PROCEDURES 1.5463 1.4345 1.3991 6.01 24,000 30,000 80% 30,000 20%

0446 4 URETHRAL & TRANSURETHRAL PROCEDURES 2.8213 2.6173 2.5527 12.50 24,000 30,000 80% 30,000 20%

0447 1 OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES 0.9695 0.8994 0.8772 1.61 24,000 30,000 80% 30,000 20%

0447 2 OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES 1.3443 1.2471 1.2163 3.08 24,000 30,000 80% 30,000 20%

0447 3 OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES 2.5258 2.3432 2.2853 6.84 24,000 30,000 80% 30,000 20%

0447 4 OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES 6.3998 5.9371 5.7905 18.38 24,000 30,000 80% 30,000 20%

0460 1 RENAL FAILURE 0.5475 0.5079 0.4954 2.75 24,000 30,000 80% 30,000 20%

0460 2 RENAL FAILURE 0.7336 0.6806 0.6638 3.61 24,000 30,000 80% 30,000 20%

0460 3 RENAL FAILURE 1.1157 1.0350 1.0094 5.09 24,000 30,000 80% 30,000 20%

0460 4 RENAL FAILURE 3.4272 3.1794 3.1009 10.83 24,000 30,000 80% 30,000 20%

0461 1 KIDNEY & URINARY TRACT MALIGNANCY 0.3745 0.3474 0.3388 2.73 24,000 30,000 80% 30,000 20%

0461 2 KIDNEY & URINARY TRACT MALIGNANCY 0.8198 0.7605 0.7417 3.87 24,000 30,000 80% 30,000 20%

0461 3 KIDNEY & URINARY TRACT MALIGNANCY 1.5436 1.4320 1.3966 6.14 24,000 30,000 80% 30,000 20%

0461 4 KIDNEY & URINARY TRACT MALIGNANCY 2.6549 2.4630 2.4022 10.66 24,000 30,000 80% 30,000 20%

0462 1 NEPHRITIS & NEPHROSIS 0.4180 0.3878 0.3782 2.40 24,000 30,000 80% 30,000 20%

0462 2 NEPHRITIS & NEPHROSIS 0.5593 0.5189 0.5061 3.35 24,000 30,000 80% 30,000 20%

0462 3 NEPHRITIS & NEPHROSIS 1.1270 1.0455 1.0197 5.71 24,000 30,000 80% 30,000 20%

0462 4 NEPHRITIS & NEPHROSIS 3.7272 3.4577 3.3723 12.70 24,000 30,000 80% 30,000 20%

0463 1 KIDNEY & URINARY TRACT INFECTIONS 0.4700 0.4360 0.4252 2.57 24,000 30,000 80% 30,000 20%

0463 2 KIDNEY & URINARY TRACT INFECTIONS 0.5933 0.5504 0.5368 3.42 24,000 30,000 80% 30,000 20%

0463 3 KIDNEY & URINARY TRACT INFECTIONS 0.9256 0.8587 0.8375 4.93 24,000 30,000 80% 30,000 20%

0463 4 KIDNEY & URINARY TRACT INFECTIONS 1.8935 1.7566 1.7132 8.45 24,000 30,000 80% 30,000 20%

0465 1 URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION 0.3810 0.3535 0.3448 1.61 24,000 30,000 80% 30,000 20%

0465 2 URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION 0.4679 0.4341 0.4234 2.02 24,000 30,000 80% 30,000 20%

0465 3 URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION 0.8327 0.7725 0.7534 3.73 24,000 30,000 80% 30,000 20%

0465 4 URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION 2.2226 2.0619 2.0110 7.45 24,000 30,000 80% 30,000 20%

0466 1 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC 0.3980 0.3692 0.3601 2.03 24,000 30,000 80% 30,000 20%

0466 2 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC 0.6258 0.5806 0.5663 3.09 24,000 30,000 80% 30,000 20%

0466 3 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC 1.0918 1.0129 0.9879 5.07 24,000 30,000 80% 30,000 20%

0466 4 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC 2.3001 2.1338 2.0811 9.19 24,000 30,000 80% 30,000 20%

0468 1 OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS 0.4589 0.4257 0.4152 2.45 24,000 30,000 80% 30,000 20%

0468 2 OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS 0.7124 0.6609 0.6446 3.54 24,000 30,000 80% 30,000 20%

0468 3 OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS 1.1265 1.0451 1.0193 5.21 24,000 30,000 80% 30,000 20%

0468 4 OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS 3.2729 3.0363 2.9613 9.89 24,000 30,000 80% 30,000 20%

0480 1 MAJOR MALE PELVIC PROCEDURES 0.9901 0.9185 0.8958 2.05 24,000 30,000 80% 30,000 20%

0480 2 MAJOR MALE PELVIC PROCEDURES 1.1221 1.0410 1.0153 2.61 24,000 30,000 80% 30,000 20%

0480 3 MAJOR MALE PELVIC PROCEDURES 1.9629 1.8210 1.7760 5.49 24,000 30,000 80% 30,000 20%

0480 4 MAJOR MALE PELVIC PROCEDURES 2.1418 1.9869 1.9378 12.30 24,000 30,000 80% 30,000 20%

0481 1 PENIS PROCEDURES 0.7187 0.6667 0.6502 2.00 24,000 30,000 80% 30,000 20%

0481 2 PENIS PROCEDURES 1.1009 1.0213 0.9961 2.17 24,000 30,000 80% 30,000 20%

0481 3 PENIS PROCEDURES 2.7735 2.5730 2.5094 6.67 24,000 30,000 80% 30,000 20%

0481 4 PENIS PROCEDURES 4.8034 4.4561 4.3460 20.09 24,000 30,000 80% 30,000 20%

0482 1 TRANSURETHRAL PROSTATECTOMY 0.5228 0.4850 0.4730 1.73 24,000 30,000 80% 30,000 20%

0482 2 TRANSURETHRAL PROSTATECTOMY 0.6790 0.6299 0.6143 2.42 24,000 30,000 80% 30,000 20%

0482 3 TRANSURETHRAL PROSTATECTOMY 1.5246 1.4144 1.3795 5.74 24,000 30,000 80% 30,000 20%

0482 4 TRANSURETHRAL PROSTATECTOMY 1.6635 1.5432 1.5051 11.84 24,000 30,000 80% 30,000 20%

0483 1 TESTES & SCROTAL PROCEDURES 0.5187 0.4812 0.4693 1.74 24,000 30,000 80% 30,000 20%

0483 2 TESTES & SCROTAL PROCEDURES 1.0261 0.9519 0.9284 4.75 24,000 30,000 80% 30,000 20%

0483 3 TESTES & SCROTAL PROCEDURES 4.0659 3.7719 3.6787 8.67 24,000 30,000 80% 30,000 20%

0483 4 TESTES & SCROTAL PROCEDURES 4.0659 3.7719 3.6787 19.00 24,000 30,000 80% 30,000 20%

0484 1 OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 0.7628 0.7076 0.6901 1.85 24,000 30,000 80% 30,000 20%

0484 2 OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 0.9307 0.8634 0.8421 2.19 24,000 30,000 80% 30,000 20%

0484 3 OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 1.5173 1.4076 1.3728 4.73 24,000 30,000 80% 30,000 20%

0484 4 OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 1.7527 1.6260 1.5858 14.22 24,000 30,000 80% 30,000 20%

0500 1 MALIGNANCY, MALE REPRODUCTIVE SYSTEM 0.3929 0.3645 0.3555 2.43 24,000 30,000 80% 30,000 20%

0500 2 MALIGNANCY, MALE REPRODUCTIVE SYSTEM 0.9076 0.8420 0.8212 4.13 24,000 30,000 80% 30,000 20%

0500 3 MALIGNANCY, MALE REPRODUCTIVE SYSTEM 1.6542 1.5346 1.4967 5.94 24,000 30,000 80% 30,000 20%

0500 4 MALIGNANCY, MALE REPRODUCTIVE SYSTEM 1.7390 1.6133 1.5735 10.23 24,000 30,000 80% 30,000 20%

0501 1 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 0.4345 0.4031 0.3931 2.46 24,000 30,000 80% 30,000 20%

0501 2 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 0.6080 0.5640 0.5501 3.47 24,000 30,000 80% 30,000 20%

0501 3 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 0.9453 0.8770 0.8553 5.09 24,000 30,000 80% 30,000 20%

0501 4 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 1.0016 0.9292 0.9062 9.26 24,000 30,000 80% 30,000 20%

0510 1 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS 1.1210 1.0400 1.0143 2.88 24,000 30,000 80% 30,000 20%

0510 2 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS 1.3977 1.2966 1.2646 4.31 24,000 30,000 80% 30,000 20%

0510 3 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS 2.6937 2.4989 2.4372 9.43 24,000 30,000 80% 30,000 20%

0510 4 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS 7.1194 6.6047 6.4416 18.70 24,000 30,000 80% 30,000 20%

0511 1 UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY 1.0377 0.9627 0.9389 3.44 24,000 30,000 80% 30,000 20%

0511 2 UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY 1.4143 1.3120 1.2796 5.29 24,000 30,000 80% 30,000 20%

0511 3 UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY 2.4796 2.3003 2.2435 9.21 24,000 30,000 80% 30,000 20%

0511 4 UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY 5.5800 5.1766 5.0487 18.54 24,000 30,000 80% 30,000 20%

0512 1 UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG 0.8929 0.8283 0.8078 2.58 24,000 30,000 80% 30,000 20%

0512 2 UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG 1.0616 0.9848 0.9605 3.62 24,000 30,000 80% 30,000 20%

0512 3 UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG 2.1492 1.9938 1.9446 7.29 24,000 30,000 80% 30,000 20%

0512 4 UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG 5.2305 4.8523 4.7324 14.90 24,000 30,000 80% 30,000 20%

0513 1 UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA 0.7024 0.6516 0.6355 2.01 24,000 30,000 80% 30,000 20%

0513 2 UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA 0.8620 0.7997 0.7799 2.58 24,000 30,000 80% 30,000 20%

0513 3 UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA 1.6844 1.5626 1.5240 5.33 24,000 30,000 80% 30,000 20%

0513 4 UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA 3.8785 3.5981 3.5092 13.22 24,000 30,000 80% 30,000 20%

0514 1 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 0.5692 0.5280 0.5150 1.43 24,000 30,000 80% 30,000 20%

0514 2 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 0.7654 0.7101 0.6926 1.82 24,000 30,000 80% 30,000 20%

0514 3 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 1.0626 0.9858 0.9615 3.64 24,000 30,000 80% 30,000 20%

0514 4 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 1.2711 1.1792 1.1501 7.40 24,000 30,000 80% 30,000 20%

0517 1 DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 0.5042 0.4677 0.4561 1.81 24,000 30,000 80% 30,000 20%

0517 2 DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 0.7205 0.6684 0.6519 2.92 24,000 30,000 80% 30,000 20%

0517 3 DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 1.6384 1.5199 1.4824 5.82 24,000 30,000 80% 30,000 20%

0517 4 DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 1.8123 1.6813 1.6398 14.36 24,000 30,000 80% 30,000 20%

0518 1 OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 0.6371 0.5910 0.5764 2.22 24,000 30,000 80% 30,000 20%

0518 2 OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 0.9514 0.8826 0.8608 3.65 24,000 30,000 80% 30,000 20%

0518 3 OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 2.1690 2.0122 1.9625 7.28 24,000 30,000 80% 30,000 20%

0518 4 OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 5.7623 5.3457 5.2137 15.59 24,000 30,000 80% 30,000 20%

0519 1 UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA 0.7136 0.6620 0.6456 2.19 24,000 30,000 80% 30,000 20%

0519 2 UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA 0.8883 0.8241 0.8037 2.72 24,000 30,000 80% 30,000 20%

0519 3 UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA 1.8130 1.6819 1.6404 5.70 24,000 30,000 80% 30,000 20%

0519 4 UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA 4.2977 3.9870 3.8885 13.77 24,000 30,000 80% 30,000 20%

0530 1 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 0.3849 0.3571 0.3483 2.34 24,000 30,000 80% 30,000 20%

0530 2 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 0.7821 0.7256 0.7077 3.67 24,000 30,000 80% 30,000 20%

0530 3 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 1.5086 1.3995 1.3649 6.45 24,000 30,000 80% 30,000 20%

0530 4 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 3.2432 3.0087 2.9344 9.81 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0531 1 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 0.4934 0.4577 0.4464 2.64 24,000 30,000 80% 30,000 20%

0531 2 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 0.6479 0.6011 0.5863 3.72 24,000 30,000 80% 30,000 20%

0531 3 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 1.0849 1.0065 0.9816 6.09 24,000 30,000 80% 30,000 20%

0531 4 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 1.2296 1.1407 1.1125 10.00 24,000 30,000 80% 30,000 20%

0532 1 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 0.4419 0.4100 0.3999 1.67 24,000 30,000 80% 30,000 20%

0532 2 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 0.5026 0.4663 0.4548 2.33 24,000 30,000 80% 30,000 20%

0532 3 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 1.0259 0.9517 0.9282 4.14 24,000 30,000 80% 30,000 20%

0532 4 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 2.6582 2.4660 2.4051 7.81 24,000 30,000 80% 30,000 20%

0540 1 CESAREAN DELIVERY 0.6375 0.5914 0.5768 3.06 24,000 30,000 80% 30,000 20%

0540 2 CESAREAN DELIVERY 0.7432 0.6895 0.6725 3.72 24,000 30,000 80% 30,000 20%

0540 3 CESAREAN DELIVERY 1.0272 0.9529 0.9294 5.93 24,000 30,000 80% 30,000 20%

0540 4 CESAREAN DELIVERY 2.3130 2.1458 2.0928 9.09 24,000 30,000 80% 30,000 20%

0541 1 VAGINAL DELIVERY W STERILIZATION &/OR D&C 0.5991 0.5558 0.5421 2.07 24,000 30,000 80% 30,000 20%

0541 2 VAGINAL DELIVERY W STERILIZATION &/OR D&C 0.6471 0.6003 0.5855 2.32 24,000 30,000 80% 30,000 20%

0541 3 VAGINAL DELIVERY W STERILIZATION &/OR D&C 0.8532 0.7915 0.7719 4.18 24,000 30,000 80% 30,000 20%

0541 4 VAGINAL DELIVERY W STERILIZATION &/OR D&C 0.8904 0.8260 0.8056 7.86 24,000 30,000 80% 30,000 20%

0542 1 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C 0.4328 0.4015 0.3916 2.01 24,000 30,000 80% 30,000 20%

0542 2 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C 0.4759 0.4415 0.4306 2.26 24,000 30,000 80% 30,000 20%

0542 3 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C 1.0498 0.9739 0.9498 4.47 24,000 30,000 80% 30,000 20%

0542 4 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C 1.4198 1.3171 1.2846 8.21 24,000 30,000 80% 30,000 20%

0544 1 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES 0.4059 0.3766 0.3673 1.28 24,000 30,000 80% 30,000 20%

0544 2 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES 0.5571 0.5168 0.5040 1.87 24,000 30,000 80% 30,000 20%

0544 3 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES 0.9570 0.8878 0.8659 3.47 24,000 30,000 80% 30,000 20%

0544 4 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES 4.3408 4.0270 3.9275 8.37 24,000 30,000 80% 30,000 20%

0545 1 ECTOPIC PREGNANCY PROCEDURE 0.6388 0.5926 0.5780 1.73 24,000 30,000 80% 30,000 20%

0545 2 ECTOPIC PREGNANCY PROCEDURE 0.7715 0.7157 0.6980 2.04 24,000 30,000 80% 30,000 20%

0545 3 ECTOPIC PREGNANCY PROCEDURE 1.0133 0.9400 0.9168 2.70 24,000 30,000 80% 30,000 20%

0545 4 ECTOPIC PREGNANCY PROCEDURE 1.0553 0.9790 0.9548 4.57 24,000 30,000 80% 30,000 20%

0546 1 OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES 0.4444 0.4123 0.4021 2.37 24,000 30,000 80% 30,000 20%

0546 2 OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES 0.7021 0.6513 0.6352 3.68 24,000 30,000 80% 30,000 20%

0546 3 OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES 1.9557 1.8143 1.7695 6.66 24,000 30,000 80% 30,000 20%

0546 4 OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES 2.4092 2.2350 2.1798 14.23 24,000 30,000 80% 30,000 20%

0560 1 VAGINAL DELIVERY 0.4116 0.3818 0.3724 1.99 24,000 30,000 80% 30,000 20%

0560 2 VAGINAL DELIVERY 0.4581 0.4250 0.4145 2.23 24,000 30,000 80% 30,000 20%

0560 3 VAGINAL DELIVERY 0.6136 0.5692 0.5551 3.25 24,000 30,000 80% 30,000 20%

0560 4 VAGINAL DELIVERY 1.5709 1.4573 1.4213 6.48 24,000 30,000 80% 30,000 20%

0561 1 POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE 0.3292 0.3054 0.2979 1.94 24,000 30,000 80% 30,000 20%

0561 2 POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE 0.4522 0.4195 0.4091 2.52 24,000 30,000 80% 30,000 20%

0561 3 POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE 0.8283 0.7684 0.7494 3.80 24,000 30,000 80% 30,000 20%

0561 4 POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE 2.0745 1.9245 1.8770 6.25 24,000 30,000 80% 30,000 20%

0563 1 THREATENED ABORTION 0.3214 0.2982 0.2908 2.38 24,000 30,000 80% 30,000 20%

0563 2 THREATENED ABORTION 0.4272 0.3963 0.3865 3.47 24,000 30,000 80% 30,000 20%

0563 3 THREATENED ABORTION 0.8439 0.7829 0.7636 5.64 24,000 30,000 80% 30,000 20%

0563 4 THREATENED ABORTION 0.8537 0.7920 0.7724 7.67 24,000 30,000 80% 30,000 20%

0564 1 ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.3200 0.2969 0.2896 1.32 24,000 30,000 80% 30,000 20%

0564 2 ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.3780 0.3507 0.3420 1.66 24,000 30,000 80% 30,000 20%

0564 3 ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.5757 0.5341 0.5209 2.62 24,000 30,000 80% 30,000 20%

0564 4 ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.5969 0.5537 0.5400 5.71 24,000 30,000 80% 30,000 20%

0565 1 FALSE LABOR 0.1992 0.1848 0.1802 1.21 24,000 30,000 80% 30,000 20%

0565 2 FALSE LABOR 0.3116 0.2891 0.2820 2.03 24,000 30,000 80% 30,000 20%

0565 3 FALSE LABOR 0.3088 0.2865 0.2794 2.06 24,000 30,000 80% 30,000 20%

0565 4 FALSE LABOR 0.3088 0.2865 0.2794 2.06 24,000 30,000 80% 30,000 20%

0566 1 OTHER ANTEPARTUM DIAGNOSES 0.3013 0.2795 0.2726 1.93 24,000 30,000 80% 30,000 20%

0566 2 OTHER ANTEPARTUM DIAGNOSES 0.4032 0.3740 0.3648 2.56 24,000 30,000 80% 30,000 20%

0566 3 OTHER ANTEPARTUM DIAGNOSES 0.6833 0.6339 0.6182 4.60 24,000 30,000 80% 30,000 20%

0566 4 OTHER ANTEPARTUM DIAGNOSES 1.8845 1.7483 1.7051 6.95 24,000 30,000 80% 30,000 20%

0580 1 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE 0.3355 0.3112 0.3035 1.51 24,000 30,000 100% 30,000 20%

0580 2 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE 0.4315 0.4003 0.3904 1.85 24,000 30,000 100% 30,000 20%

0580 3 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE 0.6485 0.6016 0.5867 1.72 24,000 30,000 100% 30,000 20%

0580 4 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE 1.0154 0.9420 0.9187 1.75 24,000 30,000 100% 30,000 20%

0581 1 NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE 0.1404 0.1302 0.1270 1.28 24,000 30,000 100% 30,000 20%

0581 2 NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE 0.1621 0.1504 0.1467 1.26 24,000 30,000 100% 30,000 20%

0581 3 NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE 0.2079 0.1929 0.1881 1.24 24,000 30,000 100% 30,000 20%

0581 4 NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE 0.3682 0.3416 0.3332 1.34 24,000 30,000 100% 30,000 20%

0583 1 NEONATE W ECMO 9.4113 8.7309 8.5152 14.00 24,000 30,000 100% 30,000 20%

0583 2 NEONATE W ECMO 9.4113 8.7309 8.5152 14.00 24,000 30,000 100% 30,000 20%

0583 3 NEONATE W ECMO 9.1157 8.4566 8.2477 25.76 24,000 30,000 100% 30,000 20%

0583 4 NEONATE W ECMO 22.9591 21.2992 20.7731 46.83 24,000 30,000 100% 30,000 20%

0588 1 NEONATE BWT <1500G W MAJOR PROCEDURE 15.7129 14.5769 14.2169 112.00 24,000 30,000 100% 30,000 20%

0588 2 NEONATE BWT <1500G W MAJOR PROCEDURE 15.7129 14.5769 14.2169 63.14 24,000 30,000 100% 30,000 20%

0588 3 NEONATE BWT <1500G W MAJOR PROCEDURE 15.7543 14.6153 14.2543 74.50 24,000 30,000 100% 30,000 20%

0588 4 NEONATE BWT <1500G W MAJOR PROCEDURE 21.8599 20.2794 19.7785 104.54 24,000 30,000 100% 30,000 20%

0589 1 NEONATE BWT <500G 0.1218 0.1130 0.1102 1.02 24,000 30,000 100% 30,000 20%

0589 2 NEONATE BWT <500G 0.1954 0.1813 0.1768 1.62 24,000 30,000 100% 30,000 20%

0589 3 NEONATE BWT <500G 0.4721 0.4380 0.4272 9.04 24,000 30,000 100% 30,000 20%

0589 4 NEONATE BWT <500G 9.5233 8.8348 8.6166 62.03 24,000 30,000 100% 30,000 20%

0591 1 NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE 0.1216 0.1128 0.1100 1.16 24,000 30,000 100% 30,000 20%

0591 2 NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE 0.4684 0.4345 0.4238 15.90 24,000 30,000 100% 30,000 20%

0591 3 NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE 7.6630 7.1090 6.9334 65.58 24,000 30,000 100% 30,000 20%

0591 4 NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE 14.6520 13.5927 13.2570 98.31 24,000 30,000 100% 30,000 20%

0593 1 NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE 6.9373 6.4357 6.2767 9.41 24,000 30,000 100% 30,000 20%

0593 2 NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE 7.5829 7.0347 6.8609 46.62 24,000 30,000 100% 30,000 20%

0593 3 NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE 11.1389 10.3336 10.0784 62.35 24,000 30,000 100% 30,000 20%

0593 4 NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE 14.4994 13.4511 13.1189 81.44 24,000 30,000 100% 30,000 20%

0602 1 NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM 4.8159 4.4677 4.3573 21.28 24,000 30,000 100% 30,000 20%

0602 2 NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM 6.9678 6.4640 6.3043 39.66 24,000 30,000 100% 30,000 20%

0602 3 NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM 8.9695 8.3210 8.1155 51.43 24,000 30,000 100% 30,000 20%

0602 4 NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM 10.8793 10.0927 9.8434 66.50 24,000 30,000 100% 30,000 20%

0603 1 NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION 3.4140 3.1672 3.0890 22.53 24,000 30,000 100% 30,000 20%

0603 2 NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION 6.1939 5.7461 5.6042 35.95 24,000 30,000 100% 30,000 20%

0603 3 NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION 7.9042 7.3327 7.1516 44.53 24,000 30,000 100% 30,000 20%

0603 4 NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION 11.4608 10.6322 10.3696 58.61 24,000 30,000 100% 30,000 20%

0607 1 NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM 4.3466 4.0323 3.9327 22.95 24,000 30,000 100% 30,000 20%

0607 2 NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM 5.5403 5.1397 5.0127 33.01 24,000 30,000 100% 30,000 20%

0607 3 NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM 7.1090 6.5950 6.4321 40.80 24,000 30,000 100% 30,000 20%

0607 4 NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM 8.6459 8.0208 7.8227 52.93 24,000 30,000 100% 30,000 20%

0608 1 NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION 3.3329 3.0919 3.0155 18.46 24,000 30,000 100% 30,000 20%

0608 2 NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION 4.6946 4.3552 4.2476 27.84 24,000 30,000 100% 30,000 20%

0608 3 NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION 6.2706 5.8172 5.6735 36.40 24,000 30,000 100% 30,000 20%

0608 4 NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION 8.9203 8.2754 8.0710 46.62 24,000 30,000 100% 30,000 20%

0609 1 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 4.5087 4.1827 4.0794 5.80 24,000 30,000 100% 30,000 20%

0609 2 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 4.6491 4.3130 4.2065 21.16 24,000 30,000 100% 30,000 20%

0609 3 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 6.2043 5.7557 5.6135 32.30 24,000 30,000 100% 30,000 20%

0609 4 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 11.7564 10.9064 10.6370 57.09 24,000 30,000 100% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0611 1 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 2.1906 2.0322 1.9820 14.64 24,000 30,000 100% 30,000 20%

0611 2 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 3.3619 3.1188 3.0418 21.11 24,000 30,000 100% 30,000 20%

0611 3 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 4.8575 4.5063 4.3950 29.58 24,000 30,000 100% 30,000 20%

0611 4 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 6.9909 6.4855 6.3253 39.06 24,000 30,000 100% 30,000 20%

0612 1 NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND 2.6582 2.4660 2.4051 16.13 24,000 30,000 100% 30,000 20%

0612 2 NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND 3.5272 3.2722 3.1914 22.27 24,000 30,000 100% 30,000 20%

0612 3 NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND 4.8264 4.4775 4.3669 28.65 24,000 30,000 100% 30,000 20%

0612 4 NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND 6.2722 5.8187 5.6750 37.79 24,000 30,000 100% 30,000 20%

0613 1 NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION 2.2565 2.0934 2.0417 14.47 24,000 30,000 100% 30,000 20%

0613 2 NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION 3.6233 3.3613 3.2783 21.39 24,000 30,000 100% 30,000 20%

0613 3 NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION 4.6385 4.3031 4.1968 26.95 24,000 30,000 100% 30,000 20%

0613 4 NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION 5.1099 4.7405 4.6234 30.65 24,000 30,000 100% 30,000 20%

0614 1 NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION 1.5818 1.4674 1.4312 10.07 24,000 30,000 100% 30,000 20%

0614 2 NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION 2.7894 2.5877 2.5238 18.82 24,000 30,000 100% 30,000 20%

0614 3 NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION 3.7110 3.4427 3.3577 24.33 24,000 30,000 100% 30,000 20%

0614 4 NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION 3.9137 3.6307 3.5410 34.29 24,000 30,000 100% 30,000 20%

0621 1 NEONATE BWT 2000-2499G W MAJOR ANOMALY 1.0243 0.9502 0.9267 7.87 24,000 30,000 100% 30,000 20%

0621 2 NEONATE BWT 2000-2499G W MAJOR ANOMALY 2.0858 1.9350 1.8872 13.15 24,000 30,000 100% 30,000 20%

0621 3 NEONATE BWT 2000-2499G W MAJOR ANOMALY 2.9748 2.7597 2.6915 19.07 24,000 30,000 100% 30,000 20%

0621 4 NEONATE BWT 2000-2499G W MAJOR ANOMALY 4.8038 4.4565 4.3464 26.85 24,000 30,000 100% 30,000 20%

0622 1 NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND 1.4983 1.3900 1.3557 9.66 24,000 30,000 100% 30,000 20%

0622 2 NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND 1.9650 1.8229 1.7779 13.16 24,000 30,000 100% 30,000 20%

0622 3 NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND 2.7907 2.5889 2.5250 16.69 24,000 30,000 100% 30,000 20%

0622 4 NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND 4.3055 3.9942 3.8955 22.29 24,000 30,000 100% 30,000 20%

0623 1 NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION 1.2243 1.1358 1.1077 8.54 24,000 30,000 100% 30,000 20%

0623 2 NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION 2.2286 2.0675 2.0164 12.81 24,000 30,000 100% 30,000 20%

0623 3 NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION 2.8098 2.6067 2.5423 16.65 24,000 30,000 100% 30,000 20%

0623 4 NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION 2.9616 2.7475 2.6796 23.20 24,000 30,000 100% 30,000 20%

0625 1 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 1.3584 1.2602 1.2291 10.00 24,000 30,000 100% 30,000 20%

0625 2 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 2.2914 2.1257 2.0732 15.65 24,000 30,000 100% 30,000 20%

0625 3 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 2.7870 2.5855 2.5216 18.35 24,000 30,000 100% 30,000 20%

0625 4 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 2.9986 2.7818 2.7131 24.18 24,000 30,000 100% 30,000 20%

0626 1 NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 0.2089 0.1938 0.1890 2.62 24,000 30,000 100% 30,000 20%

0626 2 NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 0.5482 0.5086 0.4960 4.15 24,000 30,000 100% 30,000 20%

0626 3 NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 1.1085 1.0284 1.0030 7.85 24,000 30,000 100% 30,000 20%

0626 4 NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 1.1095 1.0293 1.0039 16.50 24,000 30,000 100% 30,000 20%

0630 1 NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE 2.7531 2.5541 2.4910 4.41 24,000 30,000 100% 30,000 20%

0630 2 NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE 3.0901 2.8667 2.7959 7.53 24,000 30,000 100% 30,000 20%

0630 3 NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE 5.0049 4.6430 4.5283 14.97 24,000 30,000 100% 30,000 20%

0630 4 NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE 11.3000 10.4830 10.2241 38.19 24,000 30,000 100% 30,000 20%

0631 1 NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE 1.4180 1.3155 1.2830 3.54 24,000 30,000 100% 30,000 20%

0631 2 NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE 2.7017 2.5064 2.4445 8.87 24,000 30,000 100% 30,000 20%

0631 3 NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE 5.4743 5.0785 4.9531 22.03 24,000 30,000 100% 30,000 20%

0631 4 NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE 12.1532 11.2745 10.9960 50.52 24,000 30,000 100% 30,000 20%

0633 1 NEONATE BIRTHWT >2499G W MAJOR ANOMALY 0.2685 0.2491 0.2429 2.70 24,000 30,000 100% 30,000 20%

0633 2 NEONATE BIRTHWT >2499G W MAJOR ANOMALY 0.8226 0.7631 0.7443 5.14 24,000 30,000 100% 30,000 20%

0633 3 NEONATE BIRTHWT >2499G W MAJOR ANOMALY 2.0853 1.9345 1.8867 11.23 24,000 30,000 100% 30,000 20%

0633 4 NEONATE BIRTHWT >2499G W MAJOR ANOMALY 5.6256 5.2189 5.0900 21.60 24,000 30,000 100% 30,000 20%

0634 1 NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND 0.6947 0.6445 0.6286 4.35 24,000 30,000 100% 30,000 20%

0634 2 NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND 1.1446 1.0618 1.0356 6.85 24,000 30,000 100% 30,000 20%

0634 3 NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND 1.8933 1.7564 1.7130 10.39 24,000 30,000 100% 30,000 20%

0634 4 NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND 4.1622 3.8613 3.7659 21.76 24,000 30,000 100% 30,000 20%

0636 1 NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION 0.7389 0.6855 0.6686 5.27 24,000 30,000 100% 30,000 20%

0636 2 NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION 1.1282 1.0466 1.0207 7.34 24,000 30,000 100% 30,000 20%

0636 3 NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION 2.1866 2.0285 1.9784 10.32 24,000 30,000 100% 30,000 20%

0636 4 NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION 5.0479 4.6829 4.5672 21.58 24,000 30,000 100% 30,000 20%

0639 1 NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION 0.4486 0.4162 0.4059 3.22 24,000 30,000 100% 30,000 20%

0639 2 NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION 1.1101 1.0298 1.0044 5.54 24,000 30,000 100% 30,000 20%

0639 3 NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION 1.8355 1.7028 1.6607 8.00 24,000 30,000 100% 30,000 20%

0639 4 NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION 4.1493 3.8493 3.7542 15.72 24,000 30,000 100% 30,000 20%

0640 1 NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 0.1546 0.1434 0.1399 2.10 24,000 30,000 100% 30,000 20%

0640 2 NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 0.2412 0.2238 0.2183 2.40 24,000 30,000 100% 30,000 20%

0640 3 NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 0.5228 0.4850 0.4730 3.49 24,000 30,000 100% 30,000 20%

0640 4 NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 0.5231 0.4853 0.4733 13.31 24,000 30,000 100% 30,000 20%

0650 1 SPLENECTOMY 1.1211 1.0400 1.0143 3.53 24,000 30,000 80% 30,000 20%

0650 2 SPLENECTOMY 1.7229 1.5983 1.5588 5.53 24,000 30,000 80% 30,000 20%

0650 3 SPLENECTOMY 2.4584 2.2807 2.2244 8.75 24,000 30,000 80% 30,000 20%

0650 4 SPLENECTOMY 8.4286 7.8192 7.6261 15.19 24,000 30,000 80% 30,000 20%

0651 1 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS 0.8822 0.8184 0.7982 3.14 24,000 30,000 80% 30,000 20%

0651 2 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS 1.3664 1.2676 1.2363 4.81 24,000 30,000 80% 30,000 20%

0651 3 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS 2.2865 2.1212 2.0688 9.59 24,000 30,000 80% 30,000 20%

0651 4 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS 7.0691 6.5580 6.3960 23.47 24,000 30,000 80% 30,000 20%

0660 1 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL 0.6270 0.5817 0.5673 3.12 24,000 30,000 80% 30,000 20%

0660 2 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL 0.9047 0.8393 0.8186 4.17 24,000 30,000 80% 30,000 20%

0660 3 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL 1.7379 1.6122 1.5724 6.62 24,000 30,000 80% 30,000 20%

0660 4 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL 6.3370 5.8788 5.7336 14.95 24,000 30,000 80% 30,000 20%

0661 1 COAGULATION & PLATELET DISORDERS 0.7281 0.6755 0.6588 2.67 24,000 30,000 80% 30,000 20%

0661 2 COAGULATION & PLATELET DISORDERS 1.0168 0.9433 0.9200 3.67 24,000 30,000 80% 30,000 20%

0661 3 COAGULATION & PLATELET DISORDERS 1.6594 1.5394 1.5014 5.44 24,000 30,000 80% 30,000 20%

0661 4 COAGULATION & PLATELET DISORDERS 5.3082 4.9244 4.8028 10.52 24,000 30,000 80% 30,000 20%

0662 1 SICKLE CELL ANEMIA CRISIS 0.6279 0.5825 0.5681 3.97 24,000 30,000 80% 30,000 20%

0662 2 SICKLE CELL ANEMIA CRISIS 0.8944 0.8297 0.8092 5.31 24,000 30,000 80% 30,000 20%

0662 3 SICKLE CELL ANEMIA CRISIS 1.4009 1.2996 1.2675 7.48 24,000 30,000 80% 30,000 20%

0662 4 SICKLE CELL ANEMIA CRISIS 3.2664 3.0302 2.9554 13.05 24,000 30,000 80% 30,000 20%

0663 1 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS 0.4800 0.4453 0.4343 2.30 24,000 30,000 80% 30,000 20%

0663 2 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS 0.6617 0.6139 0.5987 3.03 24,000 30,000 80% 30,000 20%

0663 3 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS 1.0570 0.9806 0.9564 4.33 24,000 30,000 80% 30,000 20%

0663 4 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS 2.3511 2.1811 2.1272 8.19 24,000 30,000 80% 30,000 20%

0680 1 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS 1.3126 1.2177 1.1876 4.19 24,000 30,000 80% 30,000 20%

0680 2 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS 2.1336 1.9793 1.9304 6.37 24,000 30,000 80% 30,000 20%

0680 3 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS 4.0690 3.7748 3.6816 12.48 24,000 30,000 80% 30,000 20%

0680 4 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS 10.3389 9.5914 9.3545 25.63 24,000 30,000 80% 30,000 20%

0681 1 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS 0.8896 0.8253 0.8049 2.64 24,000 30,000 80% 30,000 20%

0681 2 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS 1.4642 1.3583 1.3247 4.89 24,000 30,000 80% 30,000 20%

0681 3 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS 3.4622 3.2119 3.1326 11.36 24,000 30,000 80% 30,000 20%

0681 4 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS 8.0279 7.4475 7.2635 22.85 24,000 30,000 80% 30,000 20%

0690 1 ACUTE LEUKEMIA 1.2914 1.1980 1.1684 4.68 24,000 30,000 80% 30,000 20%

0690 2 ACUTE LEUKEMIA 3.0105 2.7928 2.7238 8.09 24,000 30,000 80% 30,000 20%

0690 3 ACUTE LEUKEMIA 5.7121 5.2991 5.1682 15.77 24,000 30,000 80% 30,000 20%

0690 4 ACUTE LEUKEMIA 9.2509 8.5821 8.3701 24.64 24,000 30,000 80% 30,000 20%

0691 1 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA 0.8858 0.8218 0.8015 3.60 24,000 30,000 80% 30,000 20%

0691 2 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA 1.2914 1.1980 1.1684 5.37 24,000 30,000 80% 30,000 20%

0691 3 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA 2.4815 2.3021 2.2452 8.58 24,000 30,000 80% 30,000 20%

0691 4 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA 5.5122 5.1137 4.9874 15.00 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0692 1 RADIOTHERAPY 0.6816 0.6323 0.6167 2.92 24,000 30,000 80% 30,000 20%

0692 2 RADIOTHERAPY 1.2667 1.1751 1.1461 4.04 24,000 30,000 80% 30,000 20%

0692 3 RADIOTHERAPY 2.8925 2.6834 2.6171 9.19 24,000 30,000 80% 30,000 20%

0692 4 RADIOTHERAPY 3.2641 3.0281 2.9533 17.67 24,000 30,000 80% 30,000 20%

0693 1 CHEMOTHERAPY 0.5884 0.5459 0.5324 2.47 24,000 30,000 80% 30,000 20%

0693 2 CHEMOTHERAPY 0.8019 0.7439 0.7255 3.39 24,000 30,000 80% 30,000 20%

0693 3 CHEMOTHERAPY 1.8151 1.6839 1.6423 7.60 24,000 30,000 80% 30,000 20%

0693 4 CHEMOTHERAPY 6.7635 6.2745 6.1195 21.51 24,000 30,000 80% 30,000 20%

0694 1 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR 0.5432 0.5039 0.4915 2.74 24,000 30,000 80% 30,000 20%

0694 2 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR 0.9320 0.8646 0.8432 4.09 24,000 30,000 80% 30,000 20%

0694 3 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR 1.6945 1.5720 1.5332 6.84 24,000 30,000 80% 30,000 20%

0694 4 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR 3.3017 3.0630 2.9873 11.60 24,000 30,000 80% 30,000 20%

0710 1 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE 1.0243 0.9502 0.9267 4.85 24,000 30,000 80% 30,000 20%

0710 2 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE 1.9438 1.8033 1.7588 8.02 24,000 30,000 80% 30,000 20%

0710 3 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE 3.2636 3.0276 2.9528 12.52 24,000 30,000 80% 30,000 20%

0710 4 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE 7.2385 6.7152 6.5493 20.42 24,000 30,000 80% 30,000 20%

0711 1 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE 1.1311 1.0493 1.0234 4.56 24,000 30,000 80% 30,000 20%

0711 2 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE 1.6690 1.5483 1.5101 6.65 24,000 30,000 80% 30,000 20%

0711 3 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE 3.1207 2.8951 2.8236 10.90 24,000 30,000 80% 30,000 20%

0711 4 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE 7.5141 6.9708 6.7986 21.33 24,000 30,000 80% 30,000 20%

0720 1 SEPTICEMIA & DISSEMINATED INFECTIONS 0.6347 0.5888 0.5743 3.45 24,000 30,000 80% 30,000 20%

0720 2 SEPTICEMIA & DISSEMINATED INFECTIONS 0.9638 0.8941 0.8720 4.75 24,000 30,000 80% 30,000 20%

0720 3 SEPTICEMIA & DISSEMINATED INFECTIONS 1.5253 1.4150 1.3800 6.86 24,000 30,000 80% 30,000 20%

0720 4 SEPTICEMIA & DISSEMINATED INFECTIONS 3.0788 2.8562 2.7857 10.29 24,000 30,000 80% 30,000 20%

0721 1 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 0.6322 0.5865 0.5720 3.66 24,000 30,000 80% 30,000 20%

0721 2 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 0.8599 0.7977 0.7780 4.76 24,000 30,000 80% 30,000 20%

0721 3 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 1.4197 1.3171 1.2846 6.84 24,000 30,000 80% 30,000 20%

0721 4 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 3.1895 2.9589 2.8858 11.82 24,000 30,000 80% 30,000 20%

0722 1 FEVER 0.4122 0.3824 0.3730 2.25 24,000 30,000 80% 30,000 20%

0722 2 FEVER 0.5766 0.5349 0.5217 2.97 24,000 30,000 80% 30,000 20%

0722 3 FEVER 0.8698 0.8069 0.7870 4.32 24,000 30,000 80% 30,000 20%

0722 4 FEVER 1.6123 1.4957 1.4588 6.86 24,000 30,000 80% 30,000 20%

0723 1 VIRAL ILLNESS 0.3977 0.3689 0.3598 2.19 24,000 30,000 80% 30,000 20%

0723 2 VIRAL ILLNESS 0.4910 0.4555 0.4442 2.68 24,000 30,000 80% 30,000 20%

0723 3 VIRAL ILLNESS 0.7919 0.7346 0.7165 4.36 24,000 30,000 80% 30,000 20%

0723 4 VIRAL ILLNESS 2.7065 2.5108 2.4488 11.34 24,000 30,000 80% 30,000 20%

0724 1 OTHER INFECTIOUS & PARASITIC DISEASES 0.6035 0.5599 0.5461 3.79 24,000 30,000 80% 30,000 20%

0724 2 OTHER INFECTIOUS & PARASITIC DISEASES 0.7566 0.7019 0.6846 4.80 24,000 30,000 80% 30,000 20%

0724 3 OTHER INFECTIOUS & PARASITIC DISEASES 1.3346 1.2381 1.2075 6.82 24,000 30,000 80% 30,000 20%

0724 4 OTHER INFECTIOUS & PARASITIC DISEASES 2.9953 2.7787 2.7101 11.76 24,000 30,000 80% 30,000 20%

0740 1 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE 1.6659 1.5455 1.5073 6.48 24,000 30,000 80% 30,000 20%

0740 2 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE 2.6024 2.4142 2.3546 11.72 24,000 30,000 80% 30,000 20%

0740 3 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE 4.9051 4.5505 4.4381 15.27 24,000 30,000 80% 30,000 20%

0740 4 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE 4.7505 4.4070 4.2981 22.28 24,000 30,000 80% 30,000 20%

0750 1 SCHIZOPHRENIA 0.9197 0.8532 0.8321 9.52 24,000 30,000 80% 30,000 20%

0750 2 SCHIZOPHRENIA 0.8595 0.7974 0.7777 9.91 24,000 30,000 80% 30,000 20%

0750 3 SCHIZOPHRENIA 0.8350 0.7746 0.7555 11.83 24,000 30,000 80% 30,000 20%

0750 4 SCHIZOPHRENIA 0.8350 0.7746 0.7555 19.45 24,000 30,000 80% 30,000 20%

0751 1 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 0.5922 0.5494 0.5358 4.75 24,000 30,000 80% 30,000 20%

0751 2 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 0.7979 0.7402 0.7219 6.29 24,000 30,000 80% 30,000 20%

0751 3 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 0.9858 0.9145 0.8919 8.72 24,000 30,000 80% 30,000 20%

0751 4 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 1.0354 0.9605 0.9368 18.21 24,000 30,000 80% 30,000 20%

0752 1 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.7295 0.6768 0.6601 3.97 24,000 30,000 80% 30,000 20%

0752 2 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.7295 0.6768 0.6601 5.10 24,000 30,000 80% 30,000 20%

0752 3 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.7295 0.6768 0.6601 6.24 24,000 30,000 80% 30,000 20%

0752 4 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.7295 0.6768 0.6601 8.00 24,000 30,000 80% 30,000 20%

0753 1 BIPOLAR DISORDERS 0.6781 0.6291 0.6136 5.77 24,000 30,000 80% 30,000 20%

0753 2 BIPOLAR DISORDERS 0.6934 0.6433 0.6274 7.17 24,000 30,000 80% 30,000 20%

0753 3 BIPOLAR DISORDERS 0.6845 0.6350 0.6193 9.70 24,000 30,000 80% 30,000 20%

0753 4 BIPOLAR DISORDERS 0.6845 0.6350 0.6193 18.03 24,000 30,000 80% 30,000 20%

0754 1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 0.4456 0.4134 0.4032 3.60 24,000 30,000 80% 30,000 20%

0754 2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 0.4629 0.4294 0.4188 4.58 24,000 30,000 80% 30,000 20%

0754 3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 0.4808 0.4460 0.4350 6.08 24,000 30,000 80% 30,000 20%

0754 4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 0.4808 0.4460 0.4350 12.76 24,000 30,000 80% 30,000 20%

0755 1 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 0.3503 0.3250 0.3170 3.17 24,000 30,000 80% 30,000 20%

0755 2 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 0.5821 0.5400 0.5267 5.07 24,000 30,000 80% 30,000 20%

0755 3 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 0.6045 0.5608 0.5469 7.60 24,000 30,000 80% 30,000 20%

0755 4 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 0.6045 0.5608 0.5469 13.00 24,000 30,000 80% 30,000 20%

0756 1 ACUTE ANXIETY & DELIRIUM STATES 0.4032 0.3740 0.3648 2.53 24,000 30,000 80% 30,000 20%

0756 2 ACUTE ANXIETY & DELIRIUM STATES 0.5861 0.5437 0.5303 3.56 24,000 30,000 80% 30,000 20%

0756 3 ACUTE ANXIETY & DELIRIUM STATES 0.6740 0.6253 0.6099 4.54 24,000 30,000 80% 30,000 20%

0756 4 ACUTE ANXIETY & DELIRIUM STATES 0.7688 0.7132 0.6956 6.26 24,000 30,000 80% 30,000 20%

0757 1 ORGANIC MENTAL HEALTH DISTURBANCES 0.7987 0.7410 0.7227 6.96 24,000 30,000 80% 30,000 20%

0757 2 ORGANIC MENTAL HEALTH DISTURBANCES 0.9897 0.9181 0.8954 7.93 24,000 30,000 80% 30,000 20%

0757 3 ORGANIC MENTAL HEALTH DISTURBANCES 1.1755 1.0905 1.0636 8.68 24,000 30,000 80% 30,000 20%

0757 4 ORGANIC MENTAL HEALTH DISTURBANCES 1.2301 1.1412 1.1130 14.24 24,000 30,000 80% 30,000 20%

0758 1 CHILDHOOD BEHAVIORAL DISORDERS 0.4911 0.4556 0.4443 5.82 24,000 30,000 80% 30,000 20%

0758 2 CHILDHOOD BEHAVIORAL DISORDERS 0.4871 0.4519 0.4407 7.48 24,000 30,000 80% 30,000 20%

0758 3 CHILDHOOD BEHAVIORAL DISORDERS 0.5313 0.4929 0.4807 9.14 24,000 30,000 80% 30,000 20%

0758 4 CHILDHOOD BEHAVIORAL DISORDERS 0.5313 0.4929 0.4807 9.50 24,000 30,000 80% 30,000 20%

0759 1 EATING DISORDERS 1.5893 1.4744 1.4380 13.41 24,000 30,000 80% 30,000 20%

0759 2 EATING DISORDERS 1.3430 1.2459 1.2151 13.09 24,000 30,000 80% 30,000 20%

0759 3 EATING DISORDERS 1.7721 1.6440 1.6034 16.24 24,000 30,000 80% 30,000 20%

0759 4 EATING DISORDERS 1.9998 1.8552 1.8094 17.53 24,000 30,000 80% 30,000 20%

0760 1 OTHER MENTAL HEALTH DISORDERS 0.4045 0.3753 0.3660 6.20 24,000 30,000 80% 30,000 20%

0760 2 OTHER MENTAL HEALTH DISORDERS 0.6348 0.5889 0.5744 7.18 24,000 30,000 80% 30,000 20%

0760 3 OTHER MENTAL HEALTH DISORDERS 0.7253 0.6729 0.6563 8.68 24,000 30,000 80% 30,000 20%

0760 4 OTHER MENTAL HEALTH DISORDERS 0.7253 0.6729 0.6563 8.18 24,000 30,000 80% 30,000 20%

0770 1 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE 0.3256 0.3021 0.2946 2.01 24,000 30,000 80% 30,000 20%

0770 2 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE 0.3460 0.3210 0.3131 2.24 24,000 30,000 80% 30,000 20%

0770 3 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE 0.5135 0.4764 0.4646 2.69 24,000 30,000 80% 30,000 20%

0770 4 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE 0.5798 0.5379 0.5246 7.62 24,000 30,000 80% 30,000 20%

0772 1 ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY 0.0000 0.0000 0.0000 0.00 - - 0% - 0%

0772 2 ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY 0.0000 0.0000 0.0000 0.00 - - 0% - 0%

0772 3 ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY 0.0000 0.0000 0.0000 0.00 - - 0% - 0%

0772 4 ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY 0.0000 0.0000 0.0000 0.00 - - 0% - 0%

0773 1 OPIOID ABUSE & DEPENDENCE 0.4606 0.4273 0.4167 3.38 24,000 30,000 80% 30,000 20%

0773 2 OPIOID ABUSE & DEPENDENCE 0.5475 0.5079 0.4954 3.99 24,000 30,000 80% 30,000 20%

0773 3 OPIOID ABUSE & DEPENDENCE 0.6880 0.6383 0.6225 4.53 24,000 30,000 80% 30,000 20%

0773 4 OPIOID ABUSE & DEPENDENCE 0.7300 0.6772 0.6605 8.04 24,000 30,000 80% 30,000 20%

0774 1 COCAINE ABUSE & DEPENDENCE 0.5709 0.5296 0.5165 3.00 24,000 30,000 80% 30,000 20%

0774 2 COCAINE ABUSE & DEPENDENCE 0.5400 0.5010 0.4886 3.67 24,000 30,000 80% 30,000 20%

0774 3 COCAINE ABUSE & DEPENDENCE 0.6387 0.5925 0.5779 4.02 24,000 30,000 80% 30,000 20%

0774 4 COCAINE ABUSE & DEPENDENCE 0.6724 0.6238 0.6084 6.38 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0775 1 ALCOHOL ABUSE & DEPENDENCE 0.4354 0.4039 0.3939 2.93 24,000 30,000 80% 30,000 20%

0775 2 ALCOHOL ABUSE & DEPENDENCE 0.5780 0.5362 0.5230 3.52 24,000 30,000 80% 30,000 20%

0775 3 ALCOHOL ABUSE & DEPENDENCE 0.9983 0.9261 0.9032 5.00 24,000 30,000 80% 30,000 20%

0775 4 ALCOHOL ABUSE & DEPENDENCE 2.9710 2.7562 2.6881 10.43 24,000 30,000 80% 30,000 20%

0776 1 OTHER DRUG ABUSE & DEPENDENCE 0.5893 0.5467 0.5332 3.74 24,000 30,000 80% 30,000 20%

0776 2 OTHER DRUG ABUSE & DEPENDENCE 0.6069 0.5630 0.5491 3.79 24,000 30,000 80% 30,000 20%

0776 3 OTHER DRUG ABUSE & DEPENDENCE 0.9102 0.8444 0.8235 4.44 24,000 30,000 80% 30,000 20%

0776 4 OTHER DRUG ABUSE & DEPENDENCE 0.9631 0.8935 0.8714 7.41 24,000 30,000 80% 30,000 20%

0791 1 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 0.7214 0.6692 0.6527 2.79 24,000 30,000 80% 30,000 20%

0791 2 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1.2956 1.2019 1.1722 4.67 24,000 30,000 80% 30,000 20%

0791 3 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 2.3189 2.1512 2.0981 8.52 24,000 30,000 80% 30,000 20%

0791 4 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 6.3417 5.8832 5.7379 17.89 24,000 30,000 80% 30,000 20%

0811 1 ALLERGIC REACTIONS 0.2691 0.2496 0.2434 1.42 24,000 30,000 80% 30,000 20%

0811 2 ALLERGIC REACTIONS 0.3851 0.3573 0.3485 1.92 24,000 30,000 80% 30,000 20%

0811 3 ALLERGIC REACTIONS 0.8588 0.7967 0.7770 3.20 24,000 30,000 80% 30,000 20%

0811 4 ALLERGIC REACTIONS 1.7067 1.5833 1.5442 7.00 24,000 30,000 80% 30,000 20%

0812 1 POISONING OF MEDICINAL AGENTS 0.3677 0.3411 0.3327 1.54 24,000 30,000 80% 30,000 20%

0812 2 POISONING OF MEDICINAL AGENTS 0.4558 0.4228 0.4124 2.10 24,000 30,000 80% 30,000 20%

0812 3 POISONING OF MEDICINAL AGENTS 0.8457 0.7846 0.7652 3.16 24,000 30,000 80% 30,000 20%

0812 4 POISONING OF MEDICINAL AGENTS 2.3584 2.1879 2.1339 6.09 24,000 30,000 80% 30,000 20%

0813 1 OTHER COMPLICATIONS OF TREATMENT 0.4331 0.4018 0.3919 2.30 24,000 30,000 80% 30,000 20%

0813 2 OTHER COMPLICATIONS OF TREATMENT 0.6379 0.5918 0.5772 3.13 24,000 30,000 80% 30,000 20%

0813 3 OTHER COMPLICATIONS OF TREATMENT 1.0745 0.9968 0.9722 5.04 24,000 30,000 80% 30,000 20%

0813 4 OTHER COMPLICATIONS OF TREATMENT 2.1241 1.9705 1.9218 9.47 24,000 30,000 80% 30,000 20%

0815 1 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES 0.3441 0.3192 0.3113 1.51 24,000 30,000 80% 30,000 20%

0815 2 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES 0.5038 0.4674 0.4559 2.75 24,000 30,000 80% 30,000 20%

0815 3 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES 1.1173 1.0365 1.0109 4.06 24,000 30,000 80% 30,000 20%

0815 4 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES 2.8452 2.6395 2.5743 7.42 24,000 30,000 80% 30,000 20%

0816 1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 0.3429 0.3181 0.3102 1.61 24,000 30,000 80% 30,000 20%

0816 2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 0.4685 0.4346 0.4239 2.21 24,000 30,000 80% 30,000 20%

0816 3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 0.8311 0.7710 0.7520 3.15 24,000 30,000 80% 30,000 20%

0816 4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 2.4897 2.3097 2.2527 7.01 24,000 30,000 80% 30,000 20%

0841 1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 9.2653 8.5954 8.3831 21.39 24,000 30,000 100% 30,000 20%

0841 2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 9.2653 8.5954 8.3831 21.39 24,000 30,000 100% 30,000 20%

0841 3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 8.9077 8.2637 8.0596 21.39 24,000 30,000 100% 30,000 20%

0841 4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 17.1857 15.9432 15.5494 41.16 24,000 30,000 100% 30,000 20%

0842 1 FULL THICKNESS BURNS W SKIN GRAFT 1.8915 1.7547 1.7114 6.83 24,000 30,000 100% 30,000 20%

0842 2 FULL THICKNESS BURNS W SKIN GRAFT 3.4490 3.1996 3.1206 10.22 24,000 30,000 100% 30,000 20%

0842 3 FULL THICKNESS BURNS W SKIN GRAFT 5.0969 4.7284 4.6116 16.04 24,000 30,000 100% 30,000 20%

0842 4 FULL THICKNESS BURNS W SKIN GRAFT 9.9556 9.2358 9.0077 31.75 24,000 30,000 100% 30,000 20%

0843 1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT 0.7499 0.6957 0.6785 2.99 24,000 30,000 100% 30,000 20%

0843 2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT 1.3191 1.2237 1.1935 4.87 24,000 30,000 100% 30,000 20%

0843 3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT 2.3199 2.1522 2.0990 5.62 24,000 30,000 100% 30,000 20%

0843 4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT 2.4905 2.3104 2.2533 10.03 24,000 30,000 100% 30,000 20%

0844 1 PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT 0.4980 0.4620 0.4506 2.69 24,000 30,000 100% 30,000 20%

0844 2 PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT 1.7555 1.6286 1.5884 4.82 24,000 30,000 100% 30,000 20%

0844 3 PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT 2.8562 2.6497 2.5843 7.00 24,000 30,000 100% 30,000 20%

0844 4 PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT 11.3595 10.5382 10.2779 15.28 24,000 30,000 100% 30,000 20%

0850 1 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1.0013 0.9289 0.9060 2.69 24,000 30,000 80% 30,000 20%

0850 2 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1.4143 1.3120 1.2796 5.73 24,000 30,000 80% 30,000 20%

0850 3 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE 4.0035 3.7140 3.6223 17.14 24,000 30,000 80% 30,000 20%

0850 4 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE 11.0803 10.2792 10.0253 35.25 24,000 30,000 80% 30,000 20%

0860 1 REHABILITATION 1.2417 1.1519 1.1234 8.35 24,000 30,000 80% 30,000 20%

0860 2 REHABILITATION 1.2068 1.1195 1.0918 10.70 24,000 30,000 80% 30,000 20%

0860 3 REHABILITATION 2.7833 2.5821 2.5183 14.02 24,000 30,000 80% 30,000 20%

0860 4 REHABILITATION 5.8442 5.4217 5.2878 17.47 24,000 30,000 80% 30,000 20%

0861 1 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS 0.3547 0.3291 0.3210 2.30 24,000 30,000 80% 30,000 20%

0861 2 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS 0.5344 0.4958 0.4836 3.22 24,000 30,000 80% 30,000 20%

0861 3 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS 0.9348 0.8672 0.8458 4.79 24,000 30,000 80% 30,000 20%

0861 4 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS 1.8075 1.6768 1.6354 9.19 24,000 30,000 80% 30,000 20%

0862 1 OTHER AFTERCARE & CONVALESCENCE 0.4770 0.4425 0.4316 4.29 24,000 30,000 80% 30,000 20%

0862 2 OTHER AFTERCARE & CONVALESCENCE 0.5288 0.4906 0.4785 7.38 24,000 30,000 80% 30,000 20%

0862 3 OTHER AFTERCARE & CONVALESCENCE 1.1888 1.1028 1.0756 8.54 24,000 30,000 80% 30,000 20%

0862 4 OTHER AFTERCARE & CONVALESCENCE 1.4924 1.3845 1.3503 8.27 24,000 30,000 80% 30,000 20%

0863 1 NEONATAL AFTERCARE 0.7356 0.6824 0.6655 8.01 24,000 30,000 80% 30,000 20%

0863 2 NEONATAL AFTERCARE 1.7004 1.5775 1.5385 15.32 24,000 30,000 80% 30,000 20%

0863 3 NEONATAL AFTERCARE 2.7827 2.5815 2.5177 26.95 24,000 30,000 80% 30,000 20%

0863 4 NEONATAL AFTERCARE 3.7207 3.4517 3.3664 39.87 24,000 30,000 80% 30,000 20%

0890 1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1.2810 1.1884 1.1590 6.00 24,000 30,000 80% 30,000 20%

0890 2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1.2810 1.1884 1.1590 6.38 24,000 30,000 80% 30,000 20%

0890 3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 2.1828 2.0250 1.9750 10.14 24,000 30,000 80% 30,000 20%

0890 4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 4.2733 3.9643 3.8664 15.27 24,000 30,000 80% 30,000 20%

0892 1 HIV W MAJOR HIV RELATED CONDITION 1.2023 1.1154 1.0878 6.15 24,000 30,000 80% 30,000 20%

0892 2 HIV W MAJOR HIV RELATED CONDITION 1.0115 0.9384 0.9152 5.49 24,000 30,000 80% 30,000 20%

0892 3 HIV W MAJOR HIV RELATED CONDITION 1.3936 1.2928 1.2609 7.03 24,000 30,000 80% 30,000 20%

0892 4 HIV W MAJOR HIV RELATED CONDITION 2.9064 2.6963 2.6297 11.44 24,000 30,000 80% 30,000 20%

0893 1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 0.9727 0.9024 0.8801 5.51 24,000 30,000 80% 30,000 20%

0893 2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1.0361 0.9612 0.9375 5.82 24,000 30,000 80% 30,000 20%

0893 3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1.4682 1.3620 1.3284 8.28 24,000 30,000 80% 30,000 20%

0893 4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1.4798 1.3728 1.3389 11.10 24,000 30,000 80% 30,000 20%

0894 1 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND 0.5195 0.4819 0.4700 3.48 24,000 30,000 80% 30,000 20%

0894 2 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND 0.6978 0.6473 0.6313 4.26 24,000 30,000 80% 30,000 20%

0894 3 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND 1.0518 0.9758 0.9517 5.70 24,000 30,000 80% 30,000 20%

0894 4 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND 2.3200 2.1523 2.0991 7.67 24,000 30,000 80% 30,000 20%

0910 1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 3.6049 3.3443 3.2617 6.00 24,000 30,000 80% 30,000 20%

0910 2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 3.6049 3.3443 3.2617 7.24 24,000 30,000 80% 30,000 20%

0910 3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 3.9183 3.6350 3.5452 13.73 24,000 30,000 80% 30,000 20%

0910 4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 7.0811 6.5691 6.4068 23.46 24,000 30,000 80% 30,000 20%

0911 1 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1.9016 1.7641 1.7205 5.67 24,000 30,000 80% 30,000 20%

0911 2 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1.9143 1.7759 1.7320 6.19 24,000 30,000 80% 30,000 20%

0911 3 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 2.6230 2.4334 2.3733 8.70 24,000 30,000 80% 30,000 20%

0911 4 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 5.3231 4.9382 4.8162 18.95 24,000 30,000 80% 30,000 20%

0912 1 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 2.1047 1.9525 1.9043 6.50 24,000 30,000 80% 30,000 20%

0912 2 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 2.0997 1.9479 1.8998 6.26 24,000 30,000 80% 30,000 20%

0912 3 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 4.1753 3.8734 3.7777 9.76 24,000 30,000 80% 30,000 20%

0912 4 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 7.9845 7.4072 7.2242 18.60 24,000 30,000 80% 30,000 20%

0930 1 MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE 0.7209 0.6688 0.6523 3.00 24,000 30,000 80% 30,000 20%

0930 2 MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE 0.9887 0.9172 0.8945 3.86 24,000 30,000 80% 30,000 20%

0930 3 MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE 1.6933 1.5709 1.5321 6.06 24,000 30,000 80% 30,000 20%

0930 4 MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE 4.0637 3.7699 3.6768 14.14 24,000 30,000 80% 30,000 20%

0950 1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1.1727 1.0879 1.0610 3.02 24,000 30,000 80% 30,000 20%

0950 2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2.1453 1.9902 1.9410 6.78 24,000 30,000 80% 30,000 20%

0950 3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 4.2506 3.9433 3.8459 12.57 24,000 30,000 80% 30,000 20%

0950 4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 8.3410 7.7379 7.5468 22.50 24,000 30,000 80% 30,000 20%

*Based on date of discharge

Revised May 13, 2013

Relative Values, Average Length of Stay, and High-Cost Outlier Threshold and Percentage for APR-DRG Grouper Version 27

Fee-for-Service Inpatient Claims Billed by Acute Care General Hospitals Enrolled in PA Medical Assistance

7/1/2010* 7/1/2011* 7/1/2012* 7/1/2010* 7/1/2011* Threshold Percentage

Low-Cost Outlier

Effective 7/1/2011*

High-Cost Outlier

DRG

Severity

of Illness

(SOI) Description

Average Length

of Stay Effective

7/1/2010*

Threshold EffectivePercentage

Effective

7/1/2010*

Relative Value

Effective

0951 1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 0.8166 0.7576 0.7389 2.83 24,000 30,000 80% 30,000 20%

0951 2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1.3551 1.2571 1.2260 5.12 24,000 30,000 80% 30,000 20%

0951 3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2.9147 2.7040 2.6372 9.70 24,000 30,000 80% 30,000 20%

0951 4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 6.0805 5.6409 5.5016 17.90 24,000 30,000 80% 30,000 20%

0952 1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 0.7086 0.6574 0.6412 2.48 24,000 30,000 80% 30,000 20%

0952 2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1.1763 1.0913 1.0643 4.84 24,000 30,000 80% 30,000 20%

0952 3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2.4361 2.2600 2.2042 9.53 24,000 30,000 80% 30,000 20%

0952 4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 5.4579 5.0633 4.9382 17.66 24,000 30,000 80% 30,000 20%

0955 0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS NA NA NA NA NA NA NA NA NA

0956 0 UNGROUPABLE NA NA NA NA NA NA NA NA NA

*Based on date of discharge

Revised May 13, 2013