v34 relative weight and alos...relative value, average length of stay, high- and low-cost outlier...
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Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By A cute Care General Hospitals Enrolled In P A Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0001 1 LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT 7.9363 6.19
0001 2 LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT 8.4033 7.44
0001 3 LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT 9.8771 10.35
0001 4 LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT 17.5237 21.48
0002 1 HEART &/OR LUNG TRANSPLANT 9.5887 9.27
0002 2 HEART &/OR LUNG TRANSPLANT 12.3605 13.02
0002 3 HEART &/OR LUNG TRANSPLANT 14.8535 16.88
0002 4 HEART &/OR LUNG TRANSPLANT 23.4185 29.83
0003 1 BONE MARROW TRANSPLANT 6.2239 14.01
0003 2 BONE MARROW TRANSPLANT 7.6918 20.70
0003 3 BONE MARROW TRANSPLANT 12.6496 29.25
0003 4 BONE MARROW TRANSPLANT 20.8440 42.45
0004 1 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 5.6208 8.21
0004 2 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 7.6472 15.82
0004 3 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 11.0933 22.05
0004 4 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 15.9606 31.76
0005 1 TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE 5.3989 16.12
0005 2 TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE 5.9988 15.35
0005 3 TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE 7.3415 19.28
0005 4 TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE 10.7228 25.74
0006 1 PANCREAS TRANSPLANT 6.4639 6.55
0006 2 PANCREAS TRANSPLANT 9.0884 6.74
0006 3 PANCREAS TRANSPLANT 10.1618 9.44
0006 4 PANCREAS TRANSPLANT 16.0792 20.69
0020 1 CRANIOTOMY FOR TRAUMA 2.0828 4.46
0020 2 CRANIOTOMY FOR TRAUMA 2.8895 5.04
0020 3 CRANIOTOMY FOR TRAUMA 3.7916 8.30
0020 4 CRANIOTOMY FOR TRAUMA 7.2233 15.98
0021 1 CRANIOTOMY EXCEPT FOR TRAUMA 2.2992 2.89
0021 2 CRANIOTOMY EXCEPT FOR TRAUMA 3.0121 4.29
0021 3 CRANIOTOMY EXCEPT FOR TRAUMA 4.6161 8.05
0021 4 CRANIOTOMY EXCEPT FOR TRAUMA 8.0705 15.49
0022 1 VENTRICULAR SHUNT PROCEDURES 1.3830 1.97
0022 2 VENTRICULAR SHUNT PROCEDURES 1.7578 2.84
0022 3 VENTRICULAR SHUNT PROCEDURES 2.9806 5.66
0022 4 VENTRICULAR SHUNT PROCEDURES 7.0681 14.19
0023 1 SPINAL PROCEDURES 1.5619 2.36
0023 2 SPINAL PROCEDURES 2.2379 4.21
0023 3 SPINAL PROCEDURES 4.3238 7.83
0023 4 SPINAL PROCEDURES 7.7226 16.12
High-Cost Outlier
Threshold Percentage
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0024 1 EXTRACRANIAL VASCULAR PROCEDURES 1.2512 1.27
0024 2 EXTRACRANIAL VASCULAR PROCEDURES 1.6507 1.92
0024 3 EXTRACRANIAL VASCULAR PROCEDURES 3.2297 5.43
0024 4 EXTRACRANIAL VASCULAR PROCEDURES 6.8555 12.39
0026 1 OTHER NERVOUS SYSTEM & RELATED PROCEDURES 1.4328 1.90
0026 2 OTHER NERVOUS SYSTEM & RELATED PROCEDURES 1.8915 3.03
0026 3 OTHER NERVOUS SYSTEM & RELATED PROCEDURES 2.7106 6.04
0026 4 OTHER NERVOUS SYSTEM & RELATED PROCEDURES 5.7085 13.31
0040 1 SPINAL DISORDERS & INJURIES 1.0907 2.66
0040 2 SPINAL DISORDERS & INJURIES 1.2375 3.48
0040 3 SPINAL DISORDERS & INJURIES 1.7663 5.43
0040 4 SPINAL DISORDERS & INJURIES 4.5673 11.33
0041 1 NERVOUS SYSTEM MALIGNANCY 0.8429 2.16
0041 2 NERVOUS SYSTEM MALIGNANCY 0.9366 2.80
0041 3 NERVOUS SYSTEM MALIGNANCY 1.2793 4.19
0041 4 NERVOUS SYSTEM MALIGNANCY 2.2733 6.19
0042 1 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 0.6637 3.12
0042 2 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 0.8260 5.80
0042 3 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 1.2880 5.80
0042 4 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 3.4638 9.98
0043 1 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES 0.8718 3.00
0043 2 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES 1.1172 3.84
0043 3 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES 1.7857 5.43
0043 4 MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES 3.9846 12.14
0044 1 INTRACRANIAL HEMORRHAGE 0.9472 2.82
0044 2 INTRACRANIAL HEMORRHAGE 1.2196 3.78
0044 3 INTRACRANIAL HEMORRHAGE 1.8010 4.95
0044 4 INTRACRANIAL HEMORRHAGE 3.7436 9.12
0045 1 CVA & PRECEREBRAL OCCLUSION W INFARCT 0.8141 2.21
0045 2 CVA & PRECEREBRAL OCCLUSION W INFARCT 0.9881 3.06
0045 3 CVA & PRECEREBRAL OCCLUSION W INFARCT 1.4247 4.77
0045 4 CVA & PRECEREBRAL OCCLUSION W INFARCT 2.9656 9.17
0046 1 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT 0.7974 1.87
0046 2 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT 0.9099 2.46
0046 3 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT 1.2670 3.63
0046 4 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT 3.1466 9.26
0047 1 TRANSIENT ISCHEMIA 0.6660 1.57
0047 2 TRANSIENT ISCHEMIA 0.7230 1.97
0047 3 TRANSIENT ISCHEMIA 0.9030 2.82
0047 4 TRANSIENT ISCHEMIA 1.7950 5.68
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0048 1 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS 0.6723 2.12
0048 2 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS 0.7547 2.90
0048 3 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS 1.0529 3.94
0048 4 PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS 2.6097 9.31
0049 1 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1.0165 4.26
0049 2 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 2.2221 5.41
0049 3 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 2.7556 8.31
0049 4 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 5.0696 13.73
0050 1 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENI 0.7158 2.95
0050 2 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENI 1.3357 4.37
0050 3 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENI 2.2048 7.19
0050 4 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENI 4.5580 12.80
0051 1 VIRAL MENINGITIS 0.6156 2.33
0051 2 VIRAL MENINGITIS 0.8495 3.20
0051 3 VIRAL MENINGITIS 1.4889 5.05
0051 4 VIRAL MENINGITIS 3.0363 9.06
0052 1 NONTRAUMATIC STUPOR & COMA 0.6186 1.69
0052 2 NONTRAUMATIC STUPOR & COMA 0.7240 2.43
0052 3 NONTRAUMATIC STUPOR & COMA 0.9757 3.64
0052 4 NONTRAUMATIC STUPOR & COMA 2.4985 7.88
0053 1 SEIZURE 0.5789 1.89
0053 2 SEIZURE 0.6873 2.25
0053 3 SEIZURE 1.0277 3.18
0053 4 SEIZURE 2.5867 6.65
0054 1 MIGRAINE & OTHER HEADACHES 0.6211 1.95
0054 2 MIGRAINE & OTHER HEADACHES 0.7159 2.24
0054 3 MIGRAINE & OTHER HEADACHES 0.8756 2.86
0054 4 MIGRAINE & OTHER HEADACHES 1.6546 4.52
0055 1 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE 0.7370 1.80
0055 2 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE 0.9828 2.70
0055 3 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE 1.5714 4.44
0055 4 HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE 3.5372 9.44
0056 1 BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 0.7407 1.74
0056 2 BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1.0058 2.57
0056 3 BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1.6642 4.52
0056 4 BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 4.0571 10.26
0057 1 CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIA 0.7300 1.31
0057 2 CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIA 0.9168 1.82
0057 3 CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIA 1.2940 2.97
0057 4 CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIA 2.9644 6.69
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0058 1 OTHER DISORDERS OF NERVOUS SYSTEM 0.6923 1.97
0058 2 OTHER DISORDERS OF NERVOUS SYSTEM 0.8589 2.76
0058 3 OTHER DISORDERS OF NERVOUS SYSTEM 1.1822 3.92
0058 4 OTHER DISORDERS OF NERVOUS SYSTEM 2.7281 7.88
0070 1 ORBITAL PROCEDURES 1.0694 1.71
0070 2 ORBITAL PROCEDURES 1.4779 2.74
0070 3 ORBITAL PROCEDURES 2.4239 4.61
0070 4 ORBITAL PROCEDURES 6.0102 12.75
0073 1 EYE PROCEDURES EXCEPT ORBIT 0.9249 1.75
0073 2 EYE PROCEDURES EXCEPT ORBIT 1.0932 2.25
0073 3 EYE PROCEDURES EXCEPT ORBIT 1.8271 4.03
0073 4 EYE PROCEDURES EXCEPT ORBIT 3.9509 10.13
0080 1 ACUTE MAJOR EYE INFECTIONS 0.4806 2.50
0080 2 ACUTE MAJOR EYE INFECTIONS 0.6593 3.24
0080 3 ACUTE MAJOR EYE INFECTIONS 1.0759 5.38
0080 4 ACUTE MAJOR EYE INFECTIONS 1.8442 8.10
0082 1 EYE DISORDERS EXCEPT MAJOR INFECTIONS 0.5604 1.78
0082 2 EYE DISORDERS EXCEPT MAJOR INFECTIONS 0.7013 2.13
0082 3 EYE DISORDERS EXCEPT MAJOR INFECTIONS 1.0089 3.15
0082 4 EYE DISORDERS EXCEPT MAJOR INFECTIONS 1.8215 5.60
0089 1 MAJOR CRANIAL/FACIAL BONE PROCEDURES 1.8214 1.76
0089 2 MAJOR CRANIAL/FACIAL BONE PROCEDURES 2.3687 2.92
0089 3 MAJOR CRANIAL/FACIAL BONE PROCEDURES 3.9588 6.26
0089 4 MAJOR CRANIAL/FACIAL BONE PROCEDURES 7.0657 12.34
0090 1 MAJOR LARYNX & TRACHEA PROCEDURES 1.0554 1.99
0090 2 MAJOR LARYNX & TRACHEA PROCEDURES 2.7513 6.18
0090 3 MAJOR LARYNX & TRACHEA PROCEDURES 4.2138 10.14
0090 4 MAJOR LARYNX & TRACHEA PROCEDURES 8.1616 18.18
0091 1 OTHER MAJOR HEAD & NECK PROCEDURES 1.5430 2.26
0091 2 OTHER MAJOR HEAD & NECK PROCEDURES 2.3380 3.39
0091 3 OTHER MAJOR HEAD & NECK PROCEDURES 4.0096 7.09
0091 4 OTHER MAJOR HEAD & NECK PROCEDURES 6.3295 12.78
0092 1 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE P 1.2743 1.63
0092 2 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE P 1.7763 2.22
0092 3 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE P 2.8064 3.97
0092 4 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE P 5.5770 10.94
0093 1 SINUS & MASTOID PROCEDURES 1.2663 1.72
0093 2 SINUS & MASTOID PROCEDURES 1.5603 2.79
0093 3 SINUS & MASTOID PROCEDURES 2.6792 5.63
0093 4 SINUS & MASTOID PROCEDURES 4.3483 8.67
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0095 1 CLEFT LIP & PALATE REPAIR 0.8570 1.33
0095 2 CLEFT LIP & PALATE REPAIR 0.9953 1.65
0095 3 CLEFT LIP & PALATE REPAIR 1.5254 2.53
0095 4 CLEFT LIP & PALATE REPAIR 3.1481 5.71
0097 1 TONSIL & ADENOID PROCEDURES 0.5185 1.39
0097 2 TONSIL & ADENOID PROCEDURES 0.7959 2.04
0097 3 TONSIL & ADENOID PROCEDURES 1.5466 3.22
0097 4 TONSIL & ADENOID PROCEDURES 5.2251 9.76
0098 1 OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES 0.9088 1.68
0098 2 OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES 1.1982 2.33
0098 3 OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES 1.9284 4.54
0098 4 OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES 4.0222 10.37
0110 1 EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES 0.7118 1.88
0110 2 EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES 0.9139 2.95
0110 3 EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES 1.4776 5.08
0110 4 EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES 2.7037 9.21
0111 1 VERTIGO & OTHER LABYRINTH DISORDERS 0.5804 1.65
0111 2 VERTIGO & OTHER LABYRINTH DISORDERS 0.6436 1.99
0111 3 VERTIGO & OTHER LABYRINTH DISORDERS 0.8067 2.67
0111 4 VERTIGO & OTHER LABYRINTH DISORDERS 1.6894 5.88
0113 1 INFECTIONS OF UPPER RESPIRATORY TRACT 0.3498 1.61
0113 2 INFECTIONS OF UPPER RESPIRATORY TRACT 0.5096 2.14
0113 3 INFECTIONS OF UPPER RESPIRATORY TRACT 0.7930 3.10
0113 4 INFECTIONS OF UPPER RESPIRATORY TRACT 1.6718 4.77
0114 1 DENTAL & ORAL DISEASES & INJURIES 0.5054 1.82
0114 2 DENTAL & ORAL DISEASES & INJURIES 0.7082 2.31
0114 3 DENTAL & ORAL DISEASES & INJURIES 1.1889 4.14
0114 4 DENTAL & ORAL DISEASES & INJURIES 2.4794 8.02
0115 1 OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 0.5192 1.81
0115 2 OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 0.6912 2.22
0115 3 OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 1.0326 3.46
0115 4 OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES 2.1193 6.29
0120 1 MAJOR RESPIRATORY & CHEST PROCEDURES 1.9723 4.00
0120 2 MAJOR RESPIRATORY & CHEST PROCEDURES 2.3890 5.70
0120 3 MAJOR RESPIRATORY & CHEST PROCEDURES 3.4788 9.39
0120 4 MAJOR RESPIRATORY & CHEST PROCEDURES 5.9988 15.71
0121 1 OTHER RESPIRATORY & CHEST PROCEDURES 1.3355 2.50
0121 2 OTHER RESPIRATORY & CHEST PROCEDURES 1.7299 4.06
0121 3 OTHER RESPIRATORY & CHEST PROCEDURES 2.7185 7.46
0121 4 OTHER RESPIRATORY & CHEST PROCEDURES 5.1957 14.12
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0130 1 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOU 3.0079 9.58
0130 2 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOU 3.3373 9.92
0130 3 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOU 4.1337 11.79
0130 4 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOU 5.6772 15.30
0131 1 CYSTIC FIBROSIS - PULMONARY DISEASE 1.5167 5.12
0131 2 CYSTIC FIBROSIS - PULMONARY DISEASE 1.8717 6.43
0131 3 CYSTIC FIBROSIS - PULMONARY DISEASE 2.4287 8.26
0131 4 CYSTIC FIBROSIS - PULMONARY DISEASE 3.1239 10.56
0132 1 BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINAT 0.6003 2.49
0132 2 BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINAT 0.6705 2.77
0132 3 BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINAT 1.0363 3.54
0132 4 BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINAT 1.7253 4.15
0133 1 RESPIRATORY FAILURE 0.4462 1.72
0133 2 RESPIRATORY FAILURE 0.7804 3.21
0133 3 RESPIRATORY FAILURE 1.1856 4.36
0133 4 RESPIRATORY FAILURE 2.1596 6.20
0134 1 PULMONARY EMBOLISM 0.7092 2.77
0134 2 PULMONARY EMBOLISM 0.9201 3.53
0134 3 PULMONARY EMBOLISM 1.3431 5.04
0134 4 PULMONARY EMBOLISM 2.3306 7.84
0135 1 MAJOR CHEST & RESPIRATORY TRAUMA 0.7431 2.25
0135 2 MAJOR CHEST & RESPIRATORY TRAUMA 0.9318 2.86
0135 3 MAJOR CHEST & RESPIRATORY TRAUMA 1.3599 4.46
0135 4 MAJOR CHEST & RESPIRATORY TRAUMA 2.5650 7.03
0136 1 RESPIRATORY MALIGNANCY 0.7609 2.46
0136 2 RESPIRATORY MALIGNANCY 0.9667 3.23
0136 3 RESPIRATORY MALIGNANCY 1.4621 4.98
0136 4 RESPIRATORY MALIGNANCY 2.3707 7.74
0137 1 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 0.6957 3.19
0137 2 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 0.8989 4.13
0137 3 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 1.3352 5.59
0137 4 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 2.2606 8.06
0138 1 BRONCHIOLITIS & RSV PNEUMONIA 0.3233 1.80
0138 2 BRONCHIOLITIS & RSV PNEUMONIA 0.4893 2.35
0138 3 BRONCHIOLITIS & RSV PNEUMONIA 1.1713 3.92
0138 4 BRONCHIOLITIS & RSV PNEUMONIA 2.9121 7.05
0139 1 OTHER PNEUMONIA 0.4751 2.33
0139 2 OTHER PNEUMONIA 0.6674 3.11
0139 3 OTHER PNEUMONIA 1.0486 4.49
0139 4 OTHER PNEUMONIA 2.0172 7.28
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0140 1 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 0.5506 2.50
0140 2 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 0.6875 3.04
0140 3 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 0.9383 3.99
0140 4 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 1.8231 6.61
0141 1 ASTHMA 0.4218 1.79
0141 2 ASTHMA 0.6045 2.42
0141 3 ASTHMA 0.8664 3.29
0141 4 ASTHMA 1.6381 4.26
0142 1 INTERSTITIAL & ALVEOLAR LUNG DISEASES 0.7066 2.60
0142 2 INTERSTITIAL & ALVEOLAR LUNG DISEASES 0.8593 3.28
0142 3 INTERSTITIAL & ALVEOLAR LUNG DISEASES 1.2434 4.83
0142 4 INTERSTITIAL & ALVEOLAR LUNG DISEASES 2.2005 8.07
0143 1 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINO 0.5252 2.24
0143 2 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINO 0.7710 2.74
0143 3 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINO 1.1867 4.00
0143 4 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINO 2.0223 5.81
0144 1 RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES 0.5145 1.79
0144 2 RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES 0.6231 2.33
0144 3 RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES 0.8807 3.21
0144 4 RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES 1.5447 4.68
0160 1 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 3.3010 3.67
0160 2 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 3.8511 4.50
0160 3 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 5.8311 7.93
0160 4 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 12.9861 15.87
0161 1 CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT 4.4690 2.29
0161 2 CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT 5.7695 6.03
0161 3 CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT 9.2789 12.83
0161 4 CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT 22.2648 27.95
0162 1 CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX 4.7883 6.17
0162 2 CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX 5.3144 7.29
0162 3 CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX 7.0332 11.09
0162 4 CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX 11.0622 18.57
0163 1 CARDIAC VALVE PROCEDURES W/O AMI OR COMPLEX PDX 3.9510 5.07
0163 2 CARDIAC VALVE PROCEDURES W/O AMI OR COMPLEX PDX 4.5398 6.12
0163 3 CARDIAC VALVE PROCEDURES W/O AMI OR COMPLEX PDX 5.8219 8.66
0163 4 CARDIAC VALVE PROCEDURES W/O AMI OR COMPLEX PDX 9.3806 15.32
0165 1 CORONARY BYPASS W AMI OR COMPLEX PDX 4.1371 6.62
0165 2 CORONARY BYPASS W AMI OR COMPLEX PDX 4.4493 7.93
0165 3 CORONARY BYPASS W AMI OR COMPLEX PDX 5.6566 10.10
0165 4 CORONARY BYPASS W AMI OR COMPLEX PDX 8.4207 15.16
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0166 1 CORONARY BYPASS W/O AMI OR COMPLEX PDX 3.4204 5.33
0166 2 CORONARY BYPASS W/O AMI OR COMPLEX PDX 3.8762 6.31
0166 3 CORONARY BYPASS W/O AMI OR COMPLEX PDX 4.8417 8.39
0166 4 CORONARY BYPASS W/O AMI OR COMPLEX PDX 7.3681 13.43
0167 1 OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES 3.2128 3.60
0167 2 OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES 3.5811 5.00
0167 3 OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES 4.8799 7.29
0167 4 OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES 8.5532 14.02
0169 1 MAJOR ABDOMINAL VASCULAR PROCEDURES 1.8407 3.17
0169 2 MAJOR ABDOMINAL VASCULAR PROCEDURES 2.4324 4.42
0169 3 MAJOR ABDOMINAL VASCULAR PROCEDURES 3.9413 7.98
0169 4 MAJOR ABDOMINAL VASCULAR PROCEDURES 7.1632 14.71
0170 1 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE 2.5189 3.16
0170 2 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE 2.6870 3.83
0170 3 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE 3.2998 7.58
0170 4 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE 5.2752 12.45
0171 1 PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR 1.7404 2.18
0171 2 PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR 1.9888 3.07
0171 3 PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR 2.5302 4.95
0171 4 PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR 4.2141 9.01
0174 1 PERCUTANEOUS CORONARY INTERVENTION W AMI 2.0818 2.08
0174 2 PERCUTANEOUS CORONARY INTERVENTION W AMI 2.2423 2.53
0174 3 PERCUTANEOUS CORONARY INTERVENTION W AMI 2.8341 4.20
0174 4 PERCUTANEOUS CORONARY INTERVENTION W AMI 4.6146 7.67
0175 1 PERCUTANEOUS CORONARY INTERVENTION W/O AMI 2.0698 1.46
0175 2 PERCUTANEOUS CORONARY INTERVENTION W/O AMI 2.2814 1.94
0175 3 PERCUTANEOUS CORONARY INTERVENTION W/O AMI 2.8958 3.84
0175 4 PERCUTANEOUS CORONARY INTERVENTION W/O AMI 5.4387 7.12
0176 1 CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT 1.6349 2.25
0176 2 CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT 3.1259 1.95
0176 3 CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT 3.2571 3.39
0176 4 CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT 5.1719 9.68
0177 1 CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE 1.3466 2.09
0177 2 CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE 1.7431 3.16
0177 3 CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE 2.4719 5.35
0177 4 CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE 4.9984 12.59
0180 1 OTHER CIRCULATORY SYSTEM PROCEDURES 1.3024 2.88
0180 2 OTHER CIRCULATORY SYSTEM PROCEDURES 1.6456 4.12
0180 3 OTHER CIRCULATORY SYSTEM PROCEDURES 2.5219 7.60
0180 4 OTHER CIRCULATORY SYSTEM PROCEDURES 4.4231 12.17
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0181 1 LOWER EXTREMITY ARTERIAL PROCEDURES 1.6178 2.20
0181 2 LOWER EXTREMITY ARTERIAL PROCEDURES 2.1915 3.69
0181 3 LOWER EXTREMITY ARTERIAL PROCEDURES 3.6380 7.41
0181 4 LOWER EXTREMITY ARTERIAL PROCEDURES 6.4826 14.62
0182 1 OTHER PERIPHERAL VASCULAR PROCEDURES 2.0721 1.78
0182 2 OTHER PERIPHERAL VASCULAR PROCEDURES 2.4375 2.90
0182 3 OTHER PERIPHERAL VASCULAR PROCEDURES 3.3083 5.94
0182 4 OTHER PERIPHERAL VASCULAR PROCEDURES 5.9149 12.33
0190 1 ACUTE MYOCARDIAL INFARCTION 0.8785 2.00
0190 2 ACUTE MYOCARDIAL INFARCTION 0.9687 2.74
0190 3 ACUTE MYOCARDIAL INFARCTION 1.3198 4.45
0190 4 ACUTE MYOCARDIAL INFARCTION 2.4444 7.50
0191 1 CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE 0.9733 1.62
0191 2 CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE 1.1193 2.13
0191 3 CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE 1.4822 3.45
0191 4 CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE 2.9017 7.71
0192 1 CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS 1.0055 1.70
0192 2 CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS 1.2420 2.62
0192 3 CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS 1.8284 4.98
0192 4 CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS 3.4751 9.42
0193 1 ACUTE & SUBACUTE ENDOCARDITIS 1.0307 4.30
0193 2 ACUTE & SUBACUTE ENDOCARDITIS 1.3390 5.43
0193 3 ACUTE & SUBACUTE ENDOCARDITIS 2.0008 7.83
0193 4 ACUTE & SUBACUTE ENDOCARDITIS 3.2960 11.73
0194 1 HEART FAILURE 0.5581 2.41
0194 2 HEART FAILURE 0.7167 3.11
0194 3 HEART FAILURE 1.0689 4.45
0194 4 HEART FAILURE 2.0188 7.38
0196 1 CARDIAC ARREST & SHOCK 0.5812 1.88
0196 2 CARDIAC ARREST & SHOCK 0.6164 2.23
0196 3 CARDIAC ARREST & SHOCK 1.1699 3.78
0196 4 CARDIAC ARREST & SHOCK 2.9859 7.43
0197 1 PERIPHERAL & OTHER VASCULAR DISORDERS 0.5563 2.47
0197 2 PERIPHERAL & OTHER VASCULAR DISORDERS 0.7427 3.13
0197 3 PERIPHERAL & OTHER VASCULAR DISORDERS 1.1030 4.22
0197 4 PERIPHERAL & OTHER VASCULAR DISORDERS 2.3822 7.46
0198 1 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 0.5138 1.41
0198 2 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 0.5935 1.76
0198 3 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 0.8096 2.61
0198 4 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 1.9459 5.70
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0199 1 HYPERTENSION 0.5286 1.64
0199 2 HYPERTENSION 0.6208 2.09
0199 3 HYPERTENSION 0.8703 3.04
0199 4 HYPERTENSION 1.9839 6.02
0200 1 CARDIAC STRUCTURAL & VALVULAR DISORDERS 0.6344 1.87
0200 2 CARDIAC STRUCTURAL & VALVULAR DISORDERS 0.7506 2.46
0200 3 CARDIAC STRUCTURAL & VALVULAR DISORDERS 1.1441 3.94
0200 4 CARDIAC STRUCTURAL & VALVULAR DISORDERS 2.4374 7.28
0201 1 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 0.4741 1.65
0201 2 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 0.6142 2.30
0201 3 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 0.9433 3.68
0201 4 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 1.9572 6.74
0203 1 CHEST PAIN 0.5302 1.29
0203 2 CHEST PAIN 0.6167 1.61
0203 3 CHEST PAIN 0.7698 2.26
0203 4 CHEST PAIN 1.3977 3.76
0204 1 SYNCOPE & COLLAPSE 0.5895 1.68
0204 2 SYNCOPE & COLLAPSE 0.6657 2.13
0204 3 SYNCOPE & COLLAPSE 0.8399 2.92
0204 4 SYNCOPE & COLLAPSE 1.7218 5.51
0205 1 CARDIOMYOPATHY 0.5717 1.93
0205 2 CARDIOMYOPATHY 0.7278 2.41
0205 3 CARDIOMYOPATHY 1.0506 3.78
0205 4 CARDIOMYOPATHY 2.5780 8.06
0206 1 MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE 0.6520 1.73
0206 2 MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE 0.7668 2.55
0206 3 MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE 1.2796 4.00
0206 4 MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE 2.3939 7.68
0207 1 OTHER CIRCULATORY SYSTEM DIAGNOSES 0.5672 1.90
0207 2 OTHER CIRCULATORY SYSTEM DIAGNOSES 0.7524 2.56
0207 3 OTHER CIRCULATORY SYSTEM DIAGNOSES 1.0928 3.75
0207 4 OTHER CIRCULATORY SYSTEM DIAGNOSES 2.1311 6.56
0220 1 MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 1.4524 2.53
0220 2 MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 2.1581 5.31
0220 3 MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 3.4994 9.64
0220 4 MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 6.9435 17.13
0221 1 MAJOR SMALL & LARGE BOWEL PROCEDURES 1.4821 4.16
0221 2 MAJOR SMALL & LARGE BOWEL PROCEDURES 1.9217 6.02
0221 3 MAJOR SMALL & LARGE BOWEL PROCEDURES 3.1211 10.13
0221 4 MAJOR SMALL & LARGE BOWEL PROCEDURES 6.1778 17.09
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0222 1 OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 1.1027 1.80
0222 2 OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 1.4114 2.46
0222 3 OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 2.2872 5.44
0222 4 OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES 5.5802 13.70
0223 1 OTHER SMALL & LARGE BOWEL PROCEDURES 1.1809 3.66
0223 2 OTHER SMALL & LARGE BOWEL PROCEDURES 1.5656 5.24
0223 3 OTHER SMALL & LARGE BOWEL PROCEDURES 2.6296 8.76
0223 4 OTHER SMALL & LARGE BOWEL PROCEDURES 5.4300 15.49
0224 1 PERITONEAL ADHESIOLYSIS 1.3304 4.35
0224 2 PERITONEAL ADHESIOLYSIS 1.7421 6.30
0224 3 PERITONEAL ADHESIOLYSIS 2.6373 9.91
0224 4 PERITONEAL ADHESIOLYSIS 4.7872 15.33
0225 1 APPENDECTOMY 0.9090 1.35
0225 2 APPENDECTOMY 1.2089 2.95
0225 3 APPENDECTOMY 2.0765 5.68
0225 4 APPENDECTOMY 3.9525 10.75
0226 1 ANAL PROCEDURES 0.7372 2.03
0226 2 ANAL PROCEDURES 0.9981 3.03
0226 3 ANAL PROCEDURES 1.6271 5.21
0226 4 ANAL PROCEDURES 3.3299 10.54
0227 1 HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL 1.1458 2.40
0227 2 HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL 1.4555 3.53
0227 3 HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL 2.3618 6.34
0227 4 HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL 4.8622 11.83
0228 1 INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES 0.8619 1.67
0228 2 INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES 1.1257 2.63
0228 3 INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES 1.7292 4.72
0228 4 INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES 3.8535 10.63
0229 1 OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES 1.1915 2.82
0229 2 OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES 1.6436 4.15
0229 3 OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES 2.6776 7.55
0229 4 OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES 5.5575 14.67
0240 1 DIGESTIVE MALIGNANCY 0.7445 2.52
0240 2 DIGESTIVE MALIGNANCY 0.9542 3.30
0240 3 DIGESTIVE MALIGNANCY 1.4056 5.03
0240 4 DIGESTIVE MALIGNANCY 2.5745 8.41
0241 1 PEPTIC ULCER & GASTRITIS 0.6333 2.09
0241 2 PEPTIC ULCER & GASTRITIS 0.7855 2.68
0241 3 PEPTIC ULCER & GASTRITIS 1.1804 3.95
0241 4 PEPTIC ULCER & GASTRITIS 2.7582 8.08
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0242 1 MAJOR ESOPHAGEAL DISORDERS 0.6247 1.90
0242 2 MAJOR ESOPHAGEAL DISORDERS 0.7705 2.57
0242 3 MAJOR ESOPHAGEAL DISORDERS 1.1460 3.83
0242 4 MAJOR ESOPHAGEAL DISORDERS 2.6829 8.35
0243 1 OTHER ESOPHAGEAL DISORDERS 0.5812 1.59
0243 2 OTHER ESOPHAGEAL DISORDERS 0.7100 2.25
0243 3 OTHER ESOPHAGEAL DISORDERS 1.0247 3.66
0243 4 OTHER ESOPHAGEAL DISORDERS 2.2557 7.48
0244 1 DIVERTICULITIS & DIVERTICULOSIS 0.5429 2.48
0244 2 DIVERTICULITIS & DIVERTICULOSIS 0.7105 3.06
0244 3 DIVERTICULITIS & DIVERTICULOSIS 1.0783 4.36
0244 4 DIVERTICULITIS & DIVERTICULOSIS 2.4476 8.57
0245 1 INFLAMMATORY BOWEL DISEASE 0.6483 2.72
0245 2 INFLAMMATORY BOWEL DISEASE 0.7781 3.28
0245 3 INFLAMMATORY BOWEL DISEASE 1.1713 4.85
0245 4 INFLAMMATORY BOWEL DISEASE 2.2270 8.72
0246 1 GASTROINTESTINAL VASCULAR INSUFFICIENCY 0.6819 2.62
0246 2 GASTROINTESTINAL VASCULAR INSUFFICIENCY 0.8189 3.32
0246 3 GASTROINTESTINAL VASCULAR INSUFFICIENCY 1.2379 4.93
0246 4 GASTROINTESTINAL VASCULAR INSUFFICIENCY 2.5037 8.77
0247 1 INTESTINAL OBSTRUCTION 0.5263 2.38
0247 2 INTESTINAL OBSTRUCTION 0.6769 3.09
0247 3 INTESTINAL OBSTRUCTION 1.0732 4.67
0247 4 INTESTINAL OBSTRUCTION 2.4524 8.88
0248 1 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 0.5739 2.80
0248 2 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 0.7896 3.77
0248 3 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 1.1869 5.33
0248 4 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 2.5269 9.28
0249 1 OTHER GASTROENTERITIS, NAUSEA & VOMITING 0.4741 1.89
0249 2 OTHER GASTROENTERITIS, NAUSEA & VOMITING 0.5762 2.36
0249 3 OTHER GASTROENTERITIS, NAUSEA & VOMITING 0.8177 3.29
0249 4 OTHER GASTROENTERITIS, NAUSEA & VOMITING 1.8692 6.46
0251 1 ABDOMINAL PAIN 0.5383 1.80
0251 2 ABDOMINAL PAIN 0.6674 2.31
0251 3 ABDOMINAL PAIN 0.9018 3.16
0251 4 ABDOMINAL PAIN 1.7273 5.28
0252 1 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROC 0.5861 2.56
0252 2 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROC 0.7873 3.13
0252 3 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROC 1.2071 4.53
0252 4 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROC 2.6942 7.99
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0253 1 OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 0.5919 2.13
0253 2 OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 0.7617 2.77
0253 3 OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 1.1375 4.07
0253 4 OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 2.3562 7.31
0254 1 OTHER DIGESTIVE SYSTEM DIAGNOSES 0.5553 2.00
0254 2 OTHER DIGESTIVE SYSTEM DIAGNOSES 0.7412 2.75
0254 3 OTHER DIGESTIVE SYSTEM DIAGNOSES 1.0773 3.97
0254 4 OTHER DIGESTIVE SYSTEM DIAGNOSES 2.3102 7.24
0260 1 MAJOR PANCREAS, LIVER & SHUNT PROCEDURES 1.7327 3.45
0260 2 MAJOR PANCREAS, LIVER & SHUNT PROCEDURES 2.2897 4.72
0260 3 MAJOR PANCREAS, LIVER & SHUNT PROCEDURES 3.5937 8.51
0260 4 MAJOR PANCREAS, LIVER & SHUNT PROCEDURES 7.2796 16.58
0261 1 MAJOR BILIARY TRACT PROCEDURES 1.4411 3.58
0261 2 MAJOR BILIARY TRACT PROCEDURES 2.0051 5.69
0261 3 MAJOR BILIARY TRACT PROCEDURES 3.0322 9.05
0261 4 MAJOR BILIARY TRACT PROCEDURES 5.5707 15.20
0262 1 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 1.2561 3.41
0262 2 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 1.6566 4.83
0262 3 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 2.4797 7.42
0262 4 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 5.0711 13.28
0263 1 LAPAROSCOPIC CHOLECYSTECTOMY 1.0731 1.98
0263 2 LAPAROSCOPIC CHOLECYSTECTOMY 1.3580 2.97
0263 3 LAPAROSCOPIC CHOLECYSTECTOMY 1.8500 4.97
0263 4 LAPAROSCOPIC CHOLECYSTECTOMY 3.9206 10.73
0264 1 OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES 1.4290 3.25
0264 2 OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES 1.7503 4.16
0264 3 OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES 2.7080 7.52
0264 4 OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES 5.8815 15.74
0279 1 HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS 0.5550 2.22
0279 2 HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS 0.7024 2.78
0279 3 HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS 1.1646 4.22
0279 4 HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS 2.9371 8.71
0280 1 ALCOHOLIC LIVER DISEASE 0.5672 2.16
0280 2 ALCOHOLIC LIVER DISEASE 0.7108 2.69
0280 3 ALCOHOLIC LIVER DISEASE 1.1325 4.09
0280 4 ALCOHOLIC LIVER DISEASE 2.5556 8.10
0281 1 MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS 0.8358 2.51
0281 2 MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS 0.9914 3.21
0281 3 MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS 1.3720 4.55
0281 4 MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS 2.2361 7.20
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0282 1 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 0.5782 2.57
0282 2 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 0.7472 3.20
0282 3 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 1.2481 4.92
0282 4 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 3.4732 10.85
0283 1 OTHER DISORDERS OF THE LIVER 0.6195 2.32
0283 2 OTHER DISORDERS OF THE LIVER 0.7337 2.61
0283 3 OTHER DISORDERS OF THE LIVER 1.1059 3.87
0283 4 OTHER DISORDERS OF THE LIVER 2.2604 6.62
0284 1 DISORDERS OF GALLBLADDER & BILIARY TRACT 0.6680 2.00
0284 2 DISORDERS OF GALLBLADDER & BILIARY TRACT 0.8910 2.85
0284 3 DISORDERS OF GALLBLADDER & BILIARY TRACT 1.2840 4.31
0284 4 DISORDERS OF GALLBLADDER & BILIARY TRACT 2.5423 8.19
0301 1 HIP JOINT REPLACEMENT 1.6956 2.93
0301 2 HIP JOINT REPLACEMENT 1.8515 3.09
0301 3 HIP JOINT REPLACEMENT 2.5335 4.12
0301 4 HIP JOINT REPLACEMENT 4.1985 10.61
0302 1 KNEE JOINT REPLACEMENT 1.6182 2.60
0302 2 KNEE JOINT REPLACEMENT 1.7994 2.96
0302 3 KNEE JOINT REPLACEMENT 2.3140 4.24
0302 4 KNEE JOINT REPLACEMENT 4.2546 9.54
0303 1 DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK 4.9989 4.00
0303 2 DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK 6.0154 5.06
0303 3 DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK 8.8132 7.17
0303 4 DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK 11.9720 12.37
0304 1 DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 3.0385 2.49
0304 2 DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 3.6393 3.35
0304 3 DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 5.4809 6.14
0304 4 DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 9.1285 13.77
0305 1 AMPUTATION OF LOWER LIMB EXCEPT TOES 1.1394 4.12
0305 2 AMPUTATION OF LOWER LIMB EXCEPT TOES 1.5600 5.65
0305 3 AMPUTATION OF LOWER LIMB EXCEPT TOES 2.5528 8.92
0305 4 AMPUTATION OF LOWER LIMB EXCEPT TOES 5.3994 15.21
0308 1 HIP & FEMUR FRACTURE REPAIR 1.3812 3.55
0308 2 HIP & FEMUR FRACTURE REPAIR 1.6273 4.56
0308 3 HIP & FEMUR FRACTURE REPAIR 2.1723 6.18
0308 4 HIP & FEMUR FRACTURE REPAIR 3.7973 10.28
0309 1 OTHER SIGNIFICANT HIP & FEMUR SURGERY 1.3937 2.25
0309 2 OTHER SIGNIFICANT HIP & FEMUR SURGERY 1.9813 3.76
0309 3 OTHER SIGNIFICANT HIP & FEMUR SURGERY 2.8926 6.68
0309 4 OTHER SIGNIFICANT HIP & FEMUR SURGERY 5.6559 13.77
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0310 1 INTERVERTEBRAL DISC EXCISION & DECOMPRESSION 1.0386 1.51
0310 2 INTERVERTEBRAL DISC EXCISION & DECOMPRESSION 1.3787 2.35
0310 3 INTERVERTEBRAL DISC EXCISION & DECOMPRESSION 1.9949 4.88
0310 4 INTERVERTEBRAL DISC EXCISION & DECOMPRESSION 4.2891 11.59
0312 1 SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE 1.7123 3.23
0312 2 SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE 2.4369 5.98
0312 3 SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE 4.3943 11.52
0312 4 SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE 9.0810 24.24
0313 1 KNEE & LOWER LEG PROCEDURES EXCEPT FOOT 1.2196 2.15
0313 2 KNEE & LOWER LEG PROCEDURES EXCEPT FOOT 1.6692 3.21
0313 3 KNEE & LOWER LEG PROCEDURES EXCEPT FOOT 2.5550 5.57
0313 4 KNEE & LOWER LEG PROCEDURES EXCEPT FOOT 5.1987 12.34
0314 1 FOOT & TOE PROCEDURES 1.1154 1.89
0314 2 FOOT & TOE PROCEDURES 1.2660 3.89
0314 3 FOOT & TOE PROCEDURES 1.7655 6.15
0314 4 FOOT & TOE PROCEDURES 3.8054 11.34
0315 1 SHOULDER, UPPER ARM & FOREARM PROCEDURES EXCEPT JOINT REP 1.0059 1.53
0315 2 SHOULDER, UPPER ARM & FOREARM PROCEDURES EXCEPT JOINT REP 1.7015 2.23
0315 3 SHOULDER, UPPER ARM & FOREARM PROCEDURES EXCEPT JOINT REP 2.4479 4.89
0315 4 SHOULDER, UPPER ARM & FOREARM PROCEDURES EXCEPT JOINT REP 4.9524 10.52
0316 1 HAND & WRIST PROCEDURES 0.8758 1.79
0316 2 HAND & WRIST PROCEDURES 1.2457 2.81
0316 3 HAND & WRIST PROCEDURES 1.9986 5.34
0316 4 HAND & WRIST PROCEDURES 3.8252 11.65
0317 1 TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES 0.9672 2.32
0317 2 TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES 1.3569 3.97
0317 3 TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES 2.3304 7.33
0317 4 TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES 5.4924 15.27
0320 1 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDUR 1.1037 1.72
0320 2 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDUR 1.6966 3.60
0320 3 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDUR 2.4158 6.36
0320 4 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDUR 4.5601 11.82
0321 1 CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EX 1.8142 1.38
0321 2 CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EX 2.3514 2.21
0321 3 CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EX 3.9286 5.89
0321 4 CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EX 7.3706 14.06
0322 1 SHOULDER & ELBOW JOINT REPLACEMENT 1.6557 1.57
0322 2 SHOULDER & ELBOW JOINT REPLACEMENT 1.8047 2.05
0322 3 SHOULDER & ELBOW JOINT REPLACEMENT 2.5499 3.95
0322 4 SHOULDER & ELBOW JOINT REPLACEMENT 4.2764 8.85
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0340 1 FRACTURE OF FEMUR 0.5172 2.56
0340 2 FRACTURE OF FEMUR 0.6126 3.02
0340 3 FRACTURE OF FEMUR 0.9188 4.04
0340 4 FRACTURE OF FEMUR 2.1116 6.22
0341 1 FRACTURE OF PELVIS OR DISLOCATION OF HIP 0.5243 2.60
0341 2 FRACTURE OF PELVIS OR DISLOCATION OF HIP 0.6360 3.07
0341 3 FRACTURE OF PELVIS OR DISLOCATION OF HIP 0.8511 3.84
0341 4 FRACTURE OF PELVIS OR DISLOCATION OF HIP 2.0177 8.29
0342 1 FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK 0.5475 1.76
0342 2 FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK 0.7078 2.68
0342 3 FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK 0.9667 3.89
0342 4 FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK 2.2295 7.92
0343 1 MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL 0.8503 2.69
0343 2 MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL 1.0173 3.49
0343 3 MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL 1.6225 5.69
0343 4 MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL 2.7308 9.15
0344 1 OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL I 0.7810 3.32
0344 2 OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL I 0.9861 4.35
0344 3 OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL I 1.4736 6.45
0344 4 OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL I 2.7160 10.72
0346 1 CONNECTIVE TISSUE DISORDERS 0.7062 2.51
0346 2 CONNECTIVE TISSUE DISORDERS 0.9402 3.28
0346 3 CONNECTIVE TISSUE DISORDERS 1.5804 5.28
0346 4 CONNECTIVE TISSUE DISORDERS 3.8640 11.20
0347 1 OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES 0.6641 2.28
0347 2 OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES 0.8198 2.98
0347 3 OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES 1.1247 3.94
0347 4 OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES 2.6663 9.03
0349 1 MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PR 0.5590 1.75
0349 2 MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PR 0.7996 3.14
0349 3 MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PR 1.2189 5.05
0349 4 MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PR 2.4999 9.30
0351 1 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSE 0.5653 1.97
0351 2 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSE 0.6551 2.71
0351 3 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSE 1.0630 4.05
0351 4 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSE 2.3534 8.22
0361 1 SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES 1.4703 2.54
0361 2 SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES 1.9727 4.66
0361 3 SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES 2.8337 8.57
0361 4 SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES 6.2237 16.92
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0362 1 MASTECTOMY PROCEDURES 1.4207 1.53
0362 2 MASTECTOMY PROCEDURES 1.7363 1.87
0362 3 MASTECTOMY PROCEDURES 2.1368 3.75
0362 4 MASTECTOMY PROCEDURES 4.4997 8.93
0363 1 BREAST PROCEDURES EXCEPT MASTECTOMY 1.1086 1.62
0363 2 BREAST PROCEDURES EXCEPT MASTECTOMY 1.8705 2.59
0363 3 BREAST PROCEDURES EXCEPT MASTECTOMY 2.3880 4.32
0363 4 BREAST PROCEDURES EXCEPT MASTECTOMY 4.5995 13.55
0364 1 OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES 0.8953 2.13
0364 2 OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES 1.2374 3.68
0364 3 OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES 1.9233 6.52
0364 4 OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES 3.7686 11.62
0380 1 SKIN ULCERS 0.6135 3.10
0380 2 SKIN ULCERS 0.7355 3.60
0380 3 SKIN ULCERS 1.0632 4.95
0380 4 SKIN ULCERS 2.0871 8.45
0381 1 MAJOR SKIN DISORDERS 0.4936 2.52
0381 2 MAJOR SKIN DISORDERS 0.8699 3.62
0381 3 MAJOR SKIN DISORDERS 1.5701 5.76
0381 4 MAJOR SKIN DISORDERS 4.2454 11.16
0382 1 MALIGNANT BREAST DISORDERS 0.6696 1.98
0382 2 MALIGNANT BREAST DISORDERS 0.7943 2.93
0382 3 MALIGNANT BREAST DISORDERS 1.2588 4.48
0382 4 MALIGNANT BREAST DISORDERS 2.1172 7.24
0383 1 CELLULITIS & OTHER SKIN INFECTIONS 0.4844 2.43
0383 2 CELLULITIS & OTHER SKIN INFECTIONS 0.6447 3.27
0383 3 CELLULITIS & OTHER SKIN INFECTIONS 0.9898 4.68
0383 4 CELLULITIS & OTHER SKIN INFECTIONS 2.3416 8.50
0384 1 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEO 0.6205 1.52
0384 2 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEO 0.7355 2.19
0384 3 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEO 1.0777 3.57
0384 4 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEO 2.7265 7.19
0385 1 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS 0.4619 1.99
0385 2 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS 0.6119 2.68
0385 3 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS 0.9777 3.92
0385 4 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS 2.0073 6.99
0401 1 PITUITARY & ADRENAL PROCEDURES 1.6014 2.28
0401 2 PITUITARY & ADRENAL PROCEDURES 2.1530 3.33
0401 3 PITUITARY & ADRENAL PROCEDURES 3.6239 6.25
0401 4 PITUITARY & ADRENAL PROCEDURES 7.8409 15.10
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0403 1 PROCEDURES FOR OBESITY 1.3976 1.68
0403 2 PROCEDURES FOR OBESITY 1.5522 1.98
0403 3 PROCEDURES FOR OBESITY 2.3589 3.59
0403 4 PROCEDURES FOR OBESITY 6.6413 12.24
0404 1 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES 0.8922 1.16
0404 2 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES 1.1954 1.65
0404 3 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES 2.2748 4.70
0404 4 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES 5.4519 13.35
0405 1 OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC D 1.3875 2.45
0405 2 OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC D 1.7200 3.73
0405 3 OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC D 2.5556 6.84
0405 4 OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC D 5.8277 15.12
0420 1 DIABETES 0.4504 2.04
0420 2 DIABETES 0.5820 2.23
0420 3 DIABETES 0.8733 3.30
0420 4 DIABETES 2.1294 6.97
0421 1 MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISOR 0.6060 2.20
0421 2 MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISOR 0.6734 3.30
0421 3 MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISOR 1.0326 4.61
0421 4 MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISOR 2.1894 8.29
0422 1 HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS 0.3627 1.67
0422 2 HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS 0.5203 2.31
0422 3 HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS 0.7611 3.26
0422 4 HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS 1.6484 5.75
0423 1 INBORN ERRORS OF METABOLISM 0.6618 1.90
0423 2 INBORN ERRORS OF METABOLISM 0.8627 2.55
0423 3 INBORN ERRORS OF METABOLISM 1.3615 3.96
0423 4 INBORN ERRORS OF METABOLISM 2.6380 6.83
0424 1 OTHER ENDOCRINE DISORDERS 0.5534 2.04
0424 2 OTHER ENDOCRINE DISORDERS 0.7521 3.09
0424 3 OTHER ENDOCRINE DISORDERS 1.1402 4.54
0424 4 OTHER ENDOCRINE DISORDERS 2.4164 8.07
0425 1 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 0.4502 1.96
0425 2 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 0.5800 2.35
0425 3 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 0.8698 3.31
0425 4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 1.9512 6.58
0440 1 KIDNEY TRANSPLANT 5.3719 4.25
0440 2 KIDNEY TRANSPLANT 5.6210 4.87
0440 3 KIDNEY TRANSPLANT 6.3560 6.44
0440 4 KIDNEY TRANSPLANT 10.0625 12.53
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0441 1 MAJOR BLADDER PROCEDURES 1.5841 3.45
0441 2 MAJOR BLADDER PROCEDURES 2.4554 6.27
0441 3 MAJOR BLADDER PROCEDURES 3.3396 8.59
0441 4 MAJOR BLADDER PROCEDURES 6.7216 17.71
0442 1 KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY 1.4598 2.67
0442 2 KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY 1.6913 3.44
0442 3 KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY 2.6116 6.31
0442 4 KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY 5.1961 12.36
0443 1 KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY 1.2781 2.03
0443 2 KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY 1.5014 2.77
0443 3 KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY 2.1946 6.07
0443 4 KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY 4.5622 11.90
0444 1 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 1.1642 1.79
0444 2 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 1.5708 3.21
0444 3 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 2.5247 6.84
0444 4 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 4.7758 13.11
0445 1 OTHER BLADDER PROCEDURES 1.0093 1.73
0445 2 OTHER BLADDER PROCEDURES 1.3793 2.40
0445 3 OTHER BLADDER PROCEDURES 1.7958 5.64
0445 4 OTHER BLADDER PROCEDURES 3.7266 10.83
0446 1 URETHRAL & TRANSURETHRAL PROCEDURES 0.7728 1.54
0446 2 URETHRAL & TRANSURETHRAL PROCEDURES 0.9557 1.98
0446 3 URETHRAL & TRANSURETHRAL PROCEDURES 1.5628 4.37
0446 4 URETHRAL & TRANSURETHRAL PROCEDURES 3.3817 9.82
0447 1 OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES 1.3114 2.14
0447 2 OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES 1.6603 2.74
0447 3 OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES 2.3727 5.12
0447 4 OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES 5.4220 13.05
0461 1 KIDNEY & URINARY TRACT MALIGNANCY 0.6094 1.88
0461 2 KIDNEY & URINARY TRACT MALIGNANCY 0.7968 2.78
0461 3 KIDNEY & URINARY TRACT MALIGNANCY 1.2319 4.56
0461 4 KIDNEY & URINARY TRACT MALIGNANCY 2.2426 7.56
0462 1 NEPHRITIS & NEPHROSIS 0.5021 1.99
0462 2 NEPHRITIS & NEPHROSIS 0.7083 2.95
0462 3 NEPHRITIS & NEPHROSIS 1.3087 5.14
0462 4 NEPHRITIS & NEPHROSIS 2.6449 8.67
0463 1 KIDNEY & URINARY TRACT INFECTIONS 0.4852 2.25
0463 2 KIDNEY & URINARY TRACT INFECTIONS 0.6113 2.88
0463 3 KIDNEY & URINARY TRACT INFECTIONS 0.8490 3.95
0463 4 KIDNEY & URINARY TRACT INFECTIONS 1.6608 6.67
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0465 1 URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION 0.5337 1.45
0465 2 URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION 0.6391 1.64
0465 3 URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION 0.9795 2.94
0465 4 URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION 2.1357 6.27
0466 1 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR 0.5081 1.79
0466 2 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR 0.7076 2.76
0466 3 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR 1.0779 3.99
0466 4 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR 1.9156 6.97
0468 1 OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS 0.5311 2.03
0468 2 OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS 0.7211 2.66
0468 3 OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS 1.0513 4.01
0468 4 OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS 2.1177 7.00
0469 1 ACUTE KIDNEY INJURY 0.5029 2.17
0469 2 ACUTE KIDNEY INJURY 0.6720 2.97
0469 3 ACUTE KIDNEY INJURY 1.0882 4.59
0469 4 ACUTE KIDNEY INJURY 2.4689 8.83
0470 1 CHRONIC KIDNEY DISEASE 0.5345 1.84
0470 2 CHRONIC KIDNEY DISEASE 0.6805 2.34
0470 3 CHRONIC KIDNEY DISEASE 1.0020 3.40
0470 4 CHRONIC KIDNEY DISEASE 2.1479 6.55
0480 1 MAJOR MALE PELVIC PROCEDURES 1.3539 1.43
0480 2 MAJOR MALE PELVIC PROCEDURES 1.4921 1.76
0480 3 MAJOR MALE PELVIC PROCEDURES 2.4355 4.46
0480 4 MAJOR MALE PELVIC PROCEDURES 5.4346 12.34
0481 1 PENIS PROCEDURES 0.8662 1.74
0481 2 PENIS PROCEDURES 1.4115 1.88
0481 3 PENIS PROCEDURES 1.9653 5.44
0481 4 PENIS PROCEDURES 4.5358 12.03
0482 1 TRANSURETHRAL PROSTATECTOMY 0.7286 1.51
0482 2 TRANSURETHRAL PROSTATECTOMY 0.9507 2.25
0482 3 TRANSURETHRAL PROSTATECTOMY 1.7307 5.37
0482 4 TRANSURETHRAL PROSTATECTOMY 3.4543 9.94
0483 1 TESTES & SCROTAL PROCEDURES 0.7711 1.46
0483 2 TESTES & SCROTAL PROCEDURES 1.3948 3.59
0483 3 TESTES & SCROTAL PROCEDURES 2.3414 7.65
0483 4 TESTES & SCROTAL PROCEDURES 6.5755 14.34
0484 1 OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 1.0014 2.02
0484 2 OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 1.4291 1.59
0484 3 OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 1.8302 3.34
0484 4 OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 4.6363 14.19
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0500 1 MALIGNANCY, MALE REPRODUCTIVE SYSTEM 0.6196 1.73
0500 2 MALIGNANCY, MALE REPRODUCTIVE SYSTEM 0.7881 3.10
0500 3 MALIGNANCY, MALE REPRODUCTIVE SYSTEM 1.2464 4.83
0500 4 MALIGNANCY, MALE REPRODUCTIVE SYSTEM 2.0449 6.71
0501 1 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 0.4938 2.10
0501 2 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 0.6787 2.86
0501 3 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 1.0257 4.20
0501 4 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 2.5914 8.43
0510 1 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL 1.3697 1.87
0510 2 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL 1.6994 2.83
0510 3 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL 3.0392 6.93
0510 4 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL 7.0411 15.08
0511 1 UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNA 1.3818 2.97
0511 2 UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNA 1.7329 4.24
0511 3 UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNA 2.6014 7.04
0511 4 UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNA 5.5533 13.90
0512 1 UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL 1.2285 1.72
0512 2 UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL 1.4456 2.34
0512 3 UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL 2.2714 4.99
0512 4 UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL 4.6404 11.52
0513 1 UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEI 0.9392 1.62
0513 2 UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEI 1.1025 2.05
0513 3 UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEI 1.8087 4.14
0513 4 UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEI 4.3731 10.59
0514 1 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 0.7735 1.25
0514 2 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 1.1233 1.48
0514 3 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 1.9455 3.86
0514 4 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 5.3921 14.42
0517 1 DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 0.7443 1.58
0517 2 DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 0.9364 2.26
0517 3 DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 1.7180 4.75
0517 4 DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 4.0423 10.31
0518 1 OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 0.8856 1.79
0518 2 OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 1.2206 2.96
0518 3 OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 2.2283 6.08
0518 4 OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES 5.0732 13.59
0519 1 UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA 0.9817 1.82
0519 2 UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA 1.1774 2.39
0519 3 UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA 2.1254 4.67
0519 4 UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA 5.2788 9.90
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0530 1 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 0.5937 2.04
0530 2 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 0.7632 2.74
0530 3 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 1.2887 4.63
0530 4 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 2.3731 7.89
0531 1 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 0.5400 2.25
0531 2 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 0.7270 3.10
0531 3 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 1.1462 5.04
0531 4 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 2.2266 8.82
0532 1 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 0.4693 1.49
0532 2 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 0.5794 1.86
0532 3 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 0.9524 3.19
0532 4 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 1.9502 5.63
0540 1 CESAREAN DELIVERY 0.5981 2.82
0540 2 CESAREAN DELIVERY 0.7150 3.40
0540 3 CESAREAN DELIVERY 1.0251 4.57
0540 4 CESAREAN DELIVERY 2.8999 7.78
0541 1 VAGINAL DELIVERY W STERILIZATION &/OR D&C 0.5698 2.00
0541 2 VAGINAL DELIVERY W STERILIZATION &/OR D&C 0.6200 2.23
0541 3 VAGINAL DELIVERY W STERILIZATION &/OR D&C 0.9232 3.17
0541 4 VAGINAL DELIVERY W STERILIZATION &/OR D&C 3.2496 6.60
0542 1 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZAT 0.4225 2.03
0542 2 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZAT 0.5272 2.33
0542 3 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZAT 1.1352 3.56
0542 4 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZAT 3.7930 6.42
0544 1 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DI 0.5968 1.21
0544 2 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DI 0.7064 1.53
0544 3 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DI 1.1707 2.51
0544 4 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DI 3.2947 6.55
0545 1 ECTOPIC PREGNANCY PROCEDURE 0.8543 1.40
0545 2 ECTOPIC PREGNANCY PROCEDURE 0.9377 1.58
0545 3 ECTOPIC PREGNANCY PROCEDURE 1.1315 2.12
0545 4 ECTOPIC PREGNANCY PROCEDURE 2.0650 3.26
0546 1 OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY D 0.6517 1.90
0546 2 OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY D 0.9211 2.60
0546 3 OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY D 1.7650 4.27
0546 4 OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY D 4.8088 10.81
0560 1 VAGINAL DELIVERY 0.3529 1.90
0560 2 VAGINAL DELIVERY 0.3979 2.14
0560 3 VAGINAL DELIVERY 0.5785 2.82
0560 4 VAGINAL DELIVERY 1.7251 5.33
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0561 1 POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE 0.2768 1.70
0561 2 POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE 0.4453 2.09
0561 3 POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE 0.7156 2.96
0561 4 POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE 1.8832 5.12
0563 1 PRETERM LABOR 0.3170 1.80
0563 2 PRETERM LABOR 0.4198 2.34
0563 3 PRETERM LABOR 0.7188 3.60
0563 4 PRETERM LABOR 1.3253 9.38
0564 1 ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.3356 1.19
0564 2 ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.3918 1.38
0564 3 ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.5564 1.96
0564 4 ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 2.3679 6.70
0565 1 FALSE LABOR 0.1557 1.08
0565 2 FALSE LABOR 0.2215 1.32
0565 3 FALSE LABOR 0.3521 2.38
0565 4 FALSE LABOR 0.3875 2.62
0566 1 OTHER ANTEPARTUM DIAGNOSES 0.3109 1.65
0566 2 OTHER ANTEPARTUM DIAGNOSES 0.4177 2.13
0566 3 OTHER ANTEPARTUM DIAGNOSES 0.6408 3.33
0566 4 OTHER ANTEPARTUM DIAGNOSES 1.8217 5.98
0580 1 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE 0.2636 1.28
0580 2 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE 0.3392 1.44
0580 3 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE 0.5490 1.56
0580 4 NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE 1.0364 1.52
0581 1 NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE 0.1051 1.15
0581 2 NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE 0.1669 1.17
0581 3 NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE 0.2879 1.11
0581 4 NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE 0.5781 1.16
0583 1 NEONATE W ECMO 9.1158 11.67
0583 2 NEONATE W ECMO 10.1286 12.96
0583 3 NEONATE W ECMO 18.9892 31.09
0583 4 NEONATE W ECMO 28.3951 52.69
0588 1 NEONATE BWT <1500G W MAJOR PROCEDURE 8.9462 29.57
0588 2 NEONATE BWT <1500G W MAJOR PROCEDURE 9.9403 32.86
0588 3 NEONATE BWT <1500G W MAJOR PROCEDURE 20.2971 74.22
0588 4 NEONATE BWT <1500G W MAJOR PROCEDURE 27.1672 101.63
0589 1 NEONATE BWT <500G OR GA <24 WEEKS 15.7081 69.06
0589 2 NEONATE BWT <500G OR GA <24 WEEKS 11.0184 80.77
0589 3 NEONATE BWT <500G OR GA <24 WEEKS 7.8819 82.97
0589 4 NEONATE BWT <500G OR GA <24 WEEKS 0.2679 3.04
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0591 1 NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE 9.3809 1.00
0591 2 NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE 13.0149 46.19
0591 3 NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE 16.1615 73.21
0591 4 NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE 22.8152 98.94
0593 1 NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE 2.9086 5.71
0593 2 NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE 9.8541 42.40
0593 3 NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE 13.1240 63.31
0593 4 NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE 18.7432 84.32
0602 1 NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR M 4.2776 21.77
0602 2 NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR M 7.8543 43.39
0602 3 NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR M 10.4267 55.55
0602 4 NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR M 14.4346 68.84
0603 1 NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CON 2.4980 10.41
0603 2 NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CON 5.7379 27.48
0603 3 NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CON 8.5263 42.39
0603 4 NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CON 14.8455 61.04
0607 1 NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR M 3.8994 21.38
0607 2 NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR M 6.0881 35.03
0607 3 NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR M 8.2452 44.62
0607 4 NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR M 11.5270 56.12
0608 1 NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITI 2.6387 15.69
0608 2 NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITI 4.9655 28.53
0608 3 NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITI 7.3358 38.83
0608 4 NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITI 10.7542 47.02
0609 1 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 4.1006 3.16
0609 2 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 5.3257 14.31
0609 3 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 8.4963 30.74
0609 4 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 15.7546 50.51
0611 1 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 2.2721 12.06
0611 2 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 3.6536 19.59
0611 3 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 5.9154 31.71
0611 4 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 9.2935 38.50
0612 1 NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND 2.7618 16.33
0612 2 NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND 4.2099 24.15
0612 3 NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND 5.8215 31.87
0612 4 NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND 8.9298 38.95
0613 1 NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTI 2.3119 14.16
0613 2 NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTI 3.5807 19.56
0613 3 NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTI 5.9533 30.27
0613 4 NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTI 7.9373 35.73
High-Cost Outlier
Threshold Percentage
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0614 1 NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITI 1.5176 9.06
0614 2 NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITI 3.0307 17.60
0614 3 NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITI 4.9707 26.35
0614 4 NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITI 5.3170 28.28
0621 1 NEONATE BWT 2000-2499G W MAJOR ANOMALY 1.0623 5.46
0621 2 NEONATE BWT 2000-2499G W MAJOR ANOMALY 2.2989 11.73
0621 3 NEONATE BWT 2000-2499G W MAJOR ANOMALY 3.8721 18.19
0621 4 NEONATE BWT 2000-2499G W MAJOR ANOMALY 7.6562 26.89
0622 1 NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND 1.7175 9.91
0622 2 NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND 2.5458 13.83
0622 3 NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND 3.7116 18.35
0622 4 NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND 5.9370 21.60
0623 1 NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION 1.3615 7.71
0623 2 NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION 2.3681 12.51
0623 3 NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION 3.8513 17.85
0623 4 NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION 5.8573 21.31
0625 1 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 1.6199 9.41
0625 2 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 2.5313 14.12
0625 3 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 3.1595 16.90
0625 4 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 4.6699 17.83
0626 1 NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER 0.1610 2.42
0626 2 NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER 0.3983 3.40
0626 3 NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER 1.1626 6.97
0626 4 NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER 2.6160 15.16
0630 1 NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE 2.4652 2.70
0630 2 NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE 3.3514 4.14
0630 3 NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE 5.2736 7.25
0630 4 NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE 12.0937 18.48
0631 1 NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE 1.3842 2.11
0631 2 NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE 1.7145 3.29
0631 3 NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE 3.8534 8.66
0631 4 NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE 10.7364 27.77
0633 1 NEONATE BIRTHWT >2499G W MAJOR ANOMALY 0.3023 2.32
0633 2 NEONATE BIRTHWT >2499G W MAJOR ANOMALY 0.8604 3.49
0633 3 NEONATE BIRTHWT >2499G W MAJOR ANOMALY 1.8273 5.97
0633 4 NEONATE BIRTHWT >2499G W MAJOR ANOMALY 5.4878 12.25
0634 1 NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP CON 0.5771 3.09
0634 2 NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP CON 1.0511 4.73
0634 3 NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP CON 2.3320 8.93
0634 4 NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP CON 5.8002 15.92
High-Cost Outlier
Threshold Percentage
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0636 1 NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION 0.7811 4.52
0636 2 NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION 1.1652 5.74
0636 3 NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION 2.1937 9.54
0636 4 NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION 4.5722 14.23
0639 1 NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION 0.4516 2.50
0639 2 NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION 0.7160 3.26
0639 3 NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION 1.3893 5.19
0639 4 NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION 3.7652 10.50
0640 1 NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER 0.1144 1.92
0640 2 NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER 0.1691 2.16
0640 3 NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER 0.4112 2.91
0640 4 NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER 2.0039 9.62
0650 1 SPLENECTOMY 1.4076 2.73
0650 2 SPLENECTOMY 2.0149 4.15
0650 3 SPLENECTOMY 2.7169 6.42
0650 4 SPLENECTOMY 5.4395 12.19
0651 1 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS 1.1322 2.42
0651 2 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS 1.5899 3.35
0651 3 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS 2.8059 7.37
0651 4 OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS 5.8882 15.19
0660 1 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS 0.8284 2.55
0660 2 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS 0.8844 3.20
0660 3 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS 1.4219 4.86
0660 4 MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS 3.6943 9.68
0661 1 COAGULATION & PLATELET DISORDERS 1.0184 2.08
0661 2 COAGULATION & PLATELET DISORDERS 1.1981 2.74
0661 3 COAGULATION & PLATELET DISORDERS 2.2818 3.89
0661 4 COAGULATION & PLATELET DISORDERS 4.3522 8.71
0662 1 SICKLE CELL ANEMIA CRISIS 0.6320 3.15
0662 2 SICKLE CELL ANEMIA CRISIS 0.8657 4.12
0662 3 SICKLE CELL ANEMIA CRISIS 1.3414 5.88
0662 4 SICKLE CELL ANEMIA CRISIS 3.1517 10.65
0663 1 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS 0.5306 1.83
0663 2 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS 0.6699 2.35
0663 3 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS 0.9585 3.33
0663 4 OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS 1.7904 5.59
0680 1 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER N 1.6560 2.98
0680 2 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER N 2.2775 4.91
0680 3 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER N 3.9339 9.32
0680 4 MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER N 7.8685 18.72
High-Cost Outlier
Threshold Percentage
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0681 1 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER N 1.2066 2.02
0681 2 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER N 1.6609 3.43
0681 3 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER N 3.0524 8.36
0681 4 OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER N 7.4376 19.07
0690 1 ACUTE LEUKEMIA 1.4026 3.29
0690 2 ACUTE LEUKEMIA 2.3158 5.03
0690 3 ACUTE LEUKEMIA 4.4518 10.72
0690 4 ACUTE LEUKEMIA 8.4876 22.18
0691 1 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA 1.1881 2.97
0691 2 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA 1.3719 3.92
0691 3 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA 2.1238 6.43
0691 4 LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA 4.4668 11.84
0692 1 RADIOTHERAPY 0.8030 2.43
0692 2 RADIOTHERAPY 1.6787 3.80
0692 3 RADIOTHERAPY 2.4576 5.92
0692 4 RADIOTHERAPY 4.5463 9.83
0694 1 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN B 0.7382 2.15
0694 2 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN B 0.8699 2.97
0694 3 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN B 1.3997 4.73
0694 4 LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN B 2.7094 8.34
0695 1 CHEMOTHERAPY FOR ACUTE LEUKEMIA 0.6719 4.34
0695 2 CHEMOTHERAPY FOR ACUTE LEUKEMIA 0.9797 3.70
0695 3 CHEMOTHERAPY FOR ACUTE LEUKEMIA 2.5547 7.23
0695 4 CHEMOTHERAPY FOR ACUTE LEUKEMIA 7.0464 21.00
0696 1 OTHER CHEMOTHERAPY 0.8847 2.31
0696 2 OTHER CHEMOTHERAPY 1.0523 2.96
0696 3 OTHER CHEMOTHERAPY 1.6513 4.22
0696 4 OTHER CHEMOTHERAPY 3.8962 9.34
0710 1 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROC 1.1788 3.38
0710 2 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROC 1.6601 5.13
0710 3 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROC 2.8507 8.90
0710 4 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROC 5.8254 14.85
0711 1 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROC 1.1318 3.45
0711 2 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROC 1.5661 4.80
0711 3 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROC 2.8349 8.58
0711 4 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROC 5.8348 15.12
0720 1 SEPTICEMIA & DISSEMINATED INFECTIONS 0.5928 2.71
0720 2 SEPTICEMIA & DISSEMINATED INFECTIONS 0.7957 3.52
0720 3 SEPTICEMIA & DISSEMINATED INFECTIONS 1.3015 5.11
0720 4 SEPTICEMIA & DISSEMINATED INFECTIONS 2.8686 8.66
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0721 1 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 0.6230 2.83
0721 2 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 0.8268 3.54
0721 3 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 1.3840 5.33
0721 4 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 2.7021 8.66
0722 1 FEVER 0.4792 1.99
0722 2 FEVER 0.6427 2.47
0722 3 FEVER 0.8749 3.20
0722 4 FEVER 1.6612 4.52
0723 1 VIRAL ILLNESS 0.4227 1.81
0723 2 VIRAL ILLNESS 0.5725 2.25
0723 3 VIRAL ILLNESS 0.9254 3.44
0723 4 VIRAL ILLNESS 3.0941 7.45
0724 1 OTHER INFECTIOUS & PARASITIC DISEASES 0.7374 3.14
0724 2 OTHER INFECTIOUS & PARASITIC DISEASES 0.8700 3.64
0724 3 OTHER INFECTIOUS & PARASITIC DISEASES 1.3713 5.18
0724 4 OTHER INFECTIOUS & PARASITIC DISEASES 3.1727 9.42
0740 1 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE 1.4442 3.23
0740 2 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE 1.7381 7.38
0740 3 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE 2.9134 12.05
0740 4 MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE 5.8550 25.92
0750 1 SCHIZOPHRENIA 0.6750 6.22
0750 2 SCHIZOPHRENIA 0.8090 7.32
0750 3 SCHIZOPHRENIA 1.1802 9.11
0750 4 SCHIZOPHRENIA 2.3721 19.10
0751 1 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 0.4041 3.96
0751 2 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 0.5602 5.16
0751 3 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 0.9756 7.18
0751 4 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 1.8940 15.11
0752 1 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.3461 3.13
0752 2 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.4914 4.01
0752 3 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.8670 5.39
0752 4 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.9303 8.47
0753 1 BIPOLAR DISORDERS 0.4395 4.26
0753 2 BIPOLAR DISORDERS 0.5950 5.52
0753 3 BIPOLAR DISORDERS 0.9674 7.65
0753 4 BIPOLAR DISORDERS 1.9426 15.47
0754 1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 0.3232 3.00
0754 2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 0.4329 3.91
0754 3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 0.6741 5.27
0754 4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1.4089 9.08
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0755 1 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOS 0.2910 2.59
0755 2 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOS 0.4771 3.97
0755 3 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOS 0.6853 5.96
0755 4 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOS 1.0340 20.40
0756 1 ACUTE ANXIETY & DELIRIUM STATES 0.4722 2.22
0756 2 ACUTE ANXIETY & DELIRIUM STATES 0.5954 2.61
0756 3 ACUTE ANXIETY & DELIRIUM STATES 0.7270 2.95
0756 4 ACUTE ANXIETY & DELIRIUM STATES 1.9086 5.27
0757 1 ORGANIC MENTAL HEALTH DISTURBANCES 0.6978 5.65
0757 2 ORGANIC MENTAL HEALTH DISTURBANCES 0.8037 6.08
0757 3 ORGANIC MENTAL HEALTH DISTURBANCES 1.0346 6.39
0757 4 ORGANIC MENTAL HEALTH DISTURBANCES 2.1912 10.16
0758 1 BEHAVIORAL DISORDERS 0.4609 4.13
0758 2 BEHAVIORAL DISORDERS 0.5478 5.06
0758 3 BEHAVIORAL DISORDERS 0.9183 6.76
0758 4 BEHAVIORAL DISORDERS 1.2137 6.23
0759 1 EATING DISORDERS 1.4683 6.52
0759 2 EATING DISORDERS 1.5421 7.57
0759 3 EATING DISORDERS 1.7280 8.96
0759 4 EATING DISORDERS 2.9944 15.22
0760 1 OTHER MENTAL HEALTH DISORDERS 0.5748 3.82
0760 2 OTHER MENTAL HEALTH DISORDERS 0.7465 4.32
0760 3 OTHER MENTAL HEALTH DISORDERS 1.1260 5.16
0760 4 OTHER MENTAL HEALTH DISORDERS 2.1708 11.16
0770 1 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL 0.2573 1.68
0770 2 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL 0.3373 1.81
0770 3 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL 0.6964 2.19
0770 4 DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL 2.0807 4.96
0772 1 ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY
0772 2 ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY
0772 3 ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY
0772 4 ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY
0773 1 OPIOID ABUSE & DEPENDENCE 0.3054 3.09
0773 2 OPIOID ABUSE & DEPENDENCE 0.3905 3.41
0773 3 OPIOID ABUSE & DEPENDENCE 0.7913 3.90
0773 4 OPIOID ABUSE & DEPENDENCE 2.5042 7.76
0774 1 COCAINE ABUSE & DEPENDENCE 0.3865 2.26
0774 2 COCAINE ABUSE & DEPENDENCE 0.4015 3.05
0774 3 COCAINE ABUSE & DEPENDENCE 0.7732 3.57
0774 4 COCAINE ABUSE & DEPENDENCE 2.8294 9.13
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
0 0%
0 0%
0 0%
0 0%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
0 0%
0 0%
0 0%
0 0%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0775 1 ALCOHOL ABUSE & DEPENDENCE 0.3750 2.48
0775 2 ALCOHOL ABUSE & DEPENDENCE 0.5347 2.85
0775 3 ALCOHOL ABUSE & DEPENDENCE 1.0180 4.13
0775 4 ALCOHOL ABUSE & DEPENDENCE 2.9165 9.59
0776 1 OTHER DRUG ABUSE & DEPENDENCE 0.3562 2.58
0776 2 OTHER DRUG ABUSE & DEPENDENCE 0.4938 2.86
0776 3 OTHER DRUG ABUSE & DEPENDENCE 0.8701 3.52
0776 4 OTHER DRUG ABUSE & DEPENDENCE 2.0070 6.11
0791 1 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1.0501 2.24
0791 2 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1.5417 3.73
0791 3 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 2.4869 6.45
0791 4 O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 5.4339 13.43
0811 1 ALLERGIC REACTIONS 0.3307 1.31
0811 2 ALLERGIC REACTIONS 0.4775 1.67
0811 3 ALLERGIC REACTIONS 1.0456 3.11
0811 4 ALLERGIC REACTIONS 2.5052 6.34
0812 1 POISONING OF MEDICINAL AGENTS 0.3789 1.39
0812 2 POISONING OF MEDICINAL AGENTS 0.4826 1.82
0812 3 POISONING OF MEDICINAL AGENTS 0.8565 2.70
0812 4 POISONING OF MEDICINAL AGENTS 2.0083 5.19
0813 1 OTHER COMPLICATIONS OF TREATMENT 0.5503 1.97
0813 2 OTHER COMPLICATIONS OF TREATMENT 0.7253 2.56
0813 3 OTHER COMPLICATIONS OF TREATMENT 1.1170 3.71
0813 4 OTHER COMPLICATIONS OF TREATMENT 2.4569 7.25
0815 1 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES 0.5391 1.31
0815 2 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES 0.5726 1.95
0815 3 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES 0.9750 2.97
0815 4 OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES 3.1136 6.78
0816 1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 0.5655 1.46
0816 2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 0.6284 1.86
0816 3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 0.9098 2.54
0816 4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 2.0851 4.99
0841 1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 5.3341 15.31
0841 2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 5.4263 17.01
0841 3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 8.3502 18.90
0841 4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 21.6036 38.34
0842 1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1.6590 3.69
0842 2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2.4876 5.90
0842 3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 4.7599 10.98
0842 4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 11.3215 23.61
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0843 1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRA 0.8153 3.00
0843 2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRA 1.1248 2.84
0843 3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRA 2.0541 5.19
0843 4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRA 5.5416 18.70
0844 1 PARTIAL THICKNESS BURNS W/O SKIN GRAFT 0.5450 1.80
0844 2 PARTIAL THICKNESS BURNS W/O SKIN GRAFT 0.8219 2.74
0844 3 PARTIAL THICKNESS BURNS W/O SKIN GRAFT 1.6731 4.54
0844 4 PARTIAL THICKNESS BURNS W/O SKIN GRAFT 4.7349 12.07
0850 1 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEA 1.6820 2.05
0850 2 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEA 2.1124 3.08
0850 3 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEA 2.9023 7.64
0850 4 PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEA 5.3047 17.07
0860 1 REHABILITATION 0.9217 8.56
0860 2 REHABILITATION 1.2485 10.68
0860 3 REHABILITATION 1.7193 12.89
0860 4 REHABILITATION 2.3162 14.40
0861 1 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS 0.4732 1.91
0861 2 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS 0.6189 2.54
0861 3 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS 0.8848 3.53
0861 4 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS 1.8625 6.09
0862 1 OTHER AFTERCARE & CONVALESCENCE 0.4577 4.20
0862 2 OTHER AFTERCARE & CONVALESCENCE 0.7113 5.87
0862 3 OTHER AFTERCARE & CONVALESCENCE 1.0374 6.17
0862 4 OTHER AFTERCARE & CONVALESCENCE 1.6999 6.98
0863 1 NEONATAL AFTERCARE 0.8506 1.00
0863 2 NEONATAL AFTERCARE 2.4044 1.00
0863 3 NEONATAL AFTERCARE 4.3042 1.10
0863 4 NEONATAL AFTERCARE 10.2832 1.21
0890 1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1.0139 4.58
0890 2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1.1809 4.12
0890 3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1.8781 6.16
0890 4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 3.7820 10.79
0892 1 HIV W MAJOR HIV RELATED CONDITION 0.7895 4.07
0892 2 HIV W MAJOR HIV RELATED CONDITION 1.0442 3.70
0892 3 HIV W MAJOR HIV RELATED CONDITION 1.3683 4.72
0892 4 HIV W MAJOR HIV RELATED CONDITION 2.6556 8.29
0893 1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 0.9396 2.74
0893 2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1.0684 3.83
0893 3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1.6297 5.39
0893 4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 3.2703 9.80
High-Cost Outlier
Threshold Percentage
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 100%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
Effective October 1, 2016 based on date of discharge
Relative Value, Average Length of Stay, High- and Low-Cost Outlier Threshold and Percentage Table For APR-DRG Grouper Version 34 Fee-for-Service Inpatient Claims Billed By Acute Care General Hospitals Enrolled In PA Medical Assistance
APR-
DRG
Severity
of Illness
(SOI) APR-DRG Description
Relative
Weight
Average
Length of
Stay
0894 1 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND 0.7241 2.60
0894 2 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND 0.8705 3.11
0894 3 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND 1.2442 4.06
0894 4 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND 1.7817 7.54
0910 1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 3.3946 3.46
0910 2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 4.0260 6.66
0910 3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 5.2512 9.09
0910 4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 10.8476 19.06
0911 1 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFIC 1.8677 6.57
0911 2 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFIC 2.4549 5.68
0911 3 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFIC 3.3364 7.08
0911 4 EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFIC 7.9448 14.08
0912 1 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICA 2.2582 5.27
0912 2 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICA 2.4864 4.96
0912 3 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICA 4.0993 7.44
0912 4 MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICA 7.9010 14.06
0930 1 MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE 0.8590 2.47
0930 2 MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE 1.1556 3.00
0930 3 MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE 1.8206 4.89
0930 4 MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE 4.8199 11.91
0950 1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1.6264 2.47
0950 2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2.3881 4.39
0950 3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 3.7125 8.95
0950 4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 7.0727 17.27
0951 1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIA 1.1549 2.27
0951 2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIA 1.6497 3.69
0951 3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIA 2.7095 7.26
0951 4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIA 5.1789 13.46
0952 1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 0.9190 2.05
0952 2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1.3676 3.50
0952 3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2.3214 7.03
0952 4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 4.4035 13.12
0955 0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 0.00
0956 0 UNGROUPABLE 0.00
High-Cost Outlier
Threshold Percentage
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
30,000 80%
NA
NA
Low-Cost Outlier
Threshold Percentage
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
30,000 20%
NA
NA
Effective October 1, 2016 based on date of discharge