Psychiatric groups are no longer subdivided between IMDs located in Milwaukee and IMDs not located in Milwaukee.
The weighting factor for a DRG is based on an analysis that relates the average cost of claims under the respective DRG to the average cost of all claims. Weights are established for over 600 DRGs.
Base Rate. The statewide base rates were originally established in 1989 based on the most current Wisconsin Medicaid paid claims data available at that time. The base rates provide consideration for variance between general medical/surgical hospitals and institutions for mental disease (IMD), and hospitals in an HMO mandated county and hospitals in all other counties. The result is a proposed standard DRG rate for each of the following four groups of hospitals.
1. General Medical/Surgical Hospitals in Milwaukee County
2. General Medical/Surgical Hospitals not in Milwaukee County
3. Institutions for Mental Disease (IMD) in Milwaukee County
4. IMDs not in Milwaukee County
The base rates are adjusted annually to reflect legislatively authorized increases. Provisions of
2001 Wisconsin Act 16 (the 2001-03 biennial budget) authorized funding for a $3 million Disproportionate Share Hospital (DSH) increase in payments for inpatient hospital services in the rate year beginning July 1, 2001. A 3.4 percent administrative adjustment to the base is also included in the proposed rates for acute care hospitals.
Hospital-Specific DRG Rate. A DRG rate is calculated for each specific hospital. The appropriate standard DRG group base rate for each hospital is adjusted by the applicable wage area index for that hospital. For hospitals that qualify, additional adjustments may be made for costs related to graduate medical education, capital expenditures, serving a disproportionate share of low-income patients, and having a rural location. These adjustment factors are described below.
a) Wage Area Adjustment Index. The wage area index is a relative index based on wage data from the Health Care Financing Administration (HCFA) hospital wage survey as of May 15, 1999 and Wisconsin statewide average wage data.
b) Direct Medical Education Add-On. An adjustment for the direct costs of graduate medical education programs of qualifying Wisconsin hospitals.
c) Indirect Medical Education. An adjustment percentage based on the ratio of interns and residents to staffed beds of qualifying Wisconsin hospitals.
d) Capital Add-On. An adjustment based on audited capital costs.
e) Disproportionate Share Factor. An adjustment percentage for hospitals serving a disproportionate share of services to low-income patients.
f) Inpatient Rural Adjustment. An adjustment percentage for hospitals with a combined Medicare and Medicaid utilization rate equal to or greater than 50 percent.
Border Status Hospitals. Major and minor border status hospitals are reimbursed according to the same DRG based payment method used for in-state hospitals. With the exception of the rural adjustment, indirect medical education adjustment and direct medical education add-on, major border status hospitals receive the same hospital-specific adjustments and add-ons described above for in-state hospitals. The rates for minor border status hospitals include adjustments for wages and capital, but do not consider other hospital-specific costs or characteristics. Minor border status hospitals, may, however, request recognition of other costs or characteristics through the administrative adjustment process described in the Inpatient Hospital State Plan.
Hospitals Paid for Critical Access Hospital Inpatient Services
Critical Access Hospitals. Critical Access Hospitals (CAH) located in Wisconsin will be reimbursed according to a determination of the hospital's allowable audited costs for Medicaid inpatient services. If allowable costs are determined to exceed the total amount of DRG based payments made to the CAH for discharges of Medicaid recipients during the fiscal year, the Department will reimburse the hospital by the amount by which a CAH costs exceed payments. If payments exceed costs the Department will not recover excess payments from the hospital. However, excess payments may be applied to any amount owed to the hospital under the critical access hospital outpatient services reimbursement provisions. Critical access hospitals are not eligible for a rural hospital adjustment.
Hospitals Paid Under a Per Diem Rate for Inpatient Services
State Mental Health Institutes. State IMDs are reimbursed for hospital service days at an interim rate per diem. The interim rates are established based on the interim rate in the prior rate year adjusted for inflation.
A final reimbursement settlement is calculated based on the hospital's audited allowable costs for Medicaid inpatient services, including capital and direct medical education costs. If the hospital qualifies a disproportionate share adjustment is also included. The determination of final reimbursement may result in additional payment if allowable costs are above the interim rate per diem or recoupment of funds if allowable costs are less than total interim payments.
Rehabilitation Hospitals. Rehabilitation hospitals are reimbursed for inpatient hospital services at a rate per diem based on a three-year base allowable cost that includes direct medical education and capital costs, and any applicable disproportionate share factor, and indexed by legislatively authorized increases through the current year.
Payment Rates for Services Exempted from DRG Payment System.
Payment for certain services exempt from the DRG system are reimbursed at rates established by applying any general legislatively authorized payment increase in the current fiscal year to the rate in effect for the prior rate year. The following services and rates per diem are effective for the current rate year beginning July 1, 2001:
Services Rate Per Diem
AIDS Acute Care $597
AIDS Extended Care $329
Long-Term Ventilator Service $465
Brain Injury Care
Neurobehavioral Program Care $816
Coma-Recovery Program Care $981
Proposed Weights and Rates for the 2001-2002 Rate Year
Attachment A: Acute care DRG weights and psychiatric care DRG weights.
Attachment B. Inpatient DRG base rates (including adjustments) for each hospital.
The Wisconsin Medicaid Inpatient and Outpatient Hospital State Plans include a complete description of hospital payment methodology.
Copies of Proposed Changes and Proposed Payment Rates
For more information, interested persons may fax or write to:
Hospitals, Physicians, and Clinics Section
FAX (608) 266-1096
Bureau of Fee-for-Service Health Care Benefits
Division of Health Care Financing
P. O. Box 309
Madison, WI 53701-0309
Written Comments
Written comments on the proposed changes are welcome and should be sent to the above address. The comments received on the changes will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily at:
Division of Health Care Financing
Room 350, State Office Building
One West Wilson Street
Madison, WI
ATTACHMENT A
PROPOSED
WISCONSIN MEDICAID PROGRAM INPATIENT HOSPITAL DRG WEIGHTS
EFFECTIVE JULY 1, 2001 - JUNE 30, 2002
---------- DRG Grouper Version 18 Is Used ----------
For the year July 2001 to June 2002, Wisconsin Medicaid is using the Medicare DRG Grouper Version 18. This timing differs from Medicare which began using Version 18 October 1, 2000 and Version 19, October 1, 2001. As of October 2001, Wisconsin Medicaid has modified has its DRG grouping under Version 18 to accept ICD-9-CM changes that Medicare implemented with Version 19. As a result, hospitals can code Wisconsin Medicaid claims with the same ICD-9-CM codes as used on Medicare claims.
NOTE regarding cochlear implants grouped under DRG 49. Inpatient hospital stays for cochlear implants are paid at a 5.75 weighting factor if requested by the hospital. The hospital must specify in a written request to the Division of Health Care Financing that it wants payment at the 5.75 weight. For more information, call (608) 267-9589 or (608) 267-9698.
Description of DRG DRG Weight
Craniotomy age >17 except for trauma 1 3.4077
Craniotomy for trauma age >17 2 4.9586
Craniotomy age 0-17 3 2.1455
Spinal procedures 4 2.8562
Extracranial vascular procedures 5 1.3909
Carpel tunnel release 6 0.8478
Periph & cranial nerve & other nerv syst proc w/cc 7 2.1413
Periph & cranial nerve & other nerv syst proc w/o cc 8 1.4647
Spinal disorders and injuries 9 1.6578
Nervous system neoplasms w/cc 10 1.1606
Nervous system neoplasms w/o cc 11 0.6960
Degenerative nervous system disorders 12 1.0232
Multiple sclerosis and cerebellar ataxia 13 1.0225
Specific cerebrovascular disorders except tia 14 1.7962
Transient ischemic attack and precerebral occlusions 15 0.6863
Nonspecific cerebrovascular disorders w/cc 16 1.6175
Nonspecific cerebrovascular disorders w/o cc 17 1.2123
Cranial and peripheral nerve disorders w/cc 18 0.7606
Cranial and peripheral nerve disorders w/o cc 19 0.5712
Nervous system infection except viral meningitis 20 1.8774
Viral meningitis 21 0.5434
Hypertensive encephalopathy 22 0.9987
Nontraumatic stupor and coma 23 0.6495
Seizure and headache age >17 w/cc 24 0.7435
Seizure and headache age >17 w/o cc 25 0.5087
Seizure and headache age 0-17 26 0.5810
Traumatic stupor and coma, coma >1 hr 27 2.0530
Traumatic stupor and coma, coma <1 hr age >17 w/cc 28 1.7706
Traumatic stupor and coma, coma <1 hr age >17 w/o cc 29 0.7109
Traumatic stupor and coma, coma <1 hr age 0-17 30 0.6886
Concussion age >17 w/cc 31 0.8302
Concussion age >17 w/o cc 32 0.5145
Concussion age 0-17 33 0.2902
Other disorders of nervous system w/cc 34 1.1201
Other disorders of nervous system w/o cc 35 0.6269
Retinal procedures 36 0.8186
Orbital procedures 37 0.6768
Primary iris procedures 38 0.8711
Lens procedures with or without vitrectomy 39 0.6278
Extraocular procedures except orbit age >17 40 1.5821
Extraocular procedures except orbit age 0-17 41 1.5577
Intraocular procedures except retina, iris & lens 42 0.6262
Hyphema 43 0.7866
Acute major eye infections 44 0.6388
Neurological eye disorders 45 0.5875
Other disorders of the eye age >17 w/cc 46 0.7404
Other disorders of the eye age >17 w/o cc 47 0.6539
Other disorders of the eye age 0-17 48 0.4669
Major head & neck procedures (See note at heading) 49 1.8166
Sialoadenectomy 50 0.7384
Salivary gland procedures except sialoadenectomy 51 0.5223
Cleft lip & palate repair 52 0.6359
Sinus & mastoid procedures age >17 53 1.2633
Sinus & mastoid procedures age 0-17 54 0.6825
Miscellaneous ear, nose, mouth & throat procs. 55 1.3146
Rhinoplasty 56 0.5774
T&A proc, except tonsil. &/or adenoidectomy only, age >17 57 0.8075
T&A proc, except tonsil. &/or adenoidectomy only, age 0-17 58 1.2759
Tonsillectomy &/or adenoidectomy only, age >17 59 0.4558
Tonsillectomy &/or adenoidectomy only, age 0-17 60 0.5038
Myringotomy w/tube insertion age >17 61 1.2857
Myringotomy w/tube insertion age 0-17 62 0.8281
Other ear, nose, mouth & throat O.R. procedures 63 1.0508
Ear, nose, mouth & throat malignancy 64 0.9717
Dysequilibrium 65 0.4867
Epistaxis 66 0.5477
Epiglottitis 67 0.7445
Otitis media & uri age >17 w/cc 68 0.5761
Otitis media & uri age >17 w/o cc 69 0.4415
Otitis Media & uri age 0-17 70 0.5121
Laryngotracheitis 71 0.3381
Nasal trauma & deformity 72 0.5553
Other ear, nose, mouth & throat diagnosis age >17 73 0.5658
Other ear, nose, mouth & throat diagnosis age 0-17 74 0.6082
Major chest procedures 75 3.5755
Other resp system O.R. procedures w/cc 76 2.5787
Other resp system O.R. procedures w/o cc 77 0.8316
Pulmonary embolism 78 1.1918
Respiratory infections/inflammations age >17 w/cc 79 1.4386
Respiratory infections/inflammations age >17 w/o cc 80 0.8388
Respiratory infections/inflammations age 0-17 81 1.3171
Respiratory neoplasms 82 1.2380
Major chest trauma w/cc 83 0.9889
Major chest trauma w/o cc 84 0.6651
Pleural effusion w/cc 85 1.1290
Pleural effusion w/o cc 86 0.6814
Pulmonary edema & respiratory failure 87 1.8057
Chronic obstructive pulmonary disease 88 0.7673
Simple pneumonia & pleurisy age >17 w/cc 89 0.9140
Simple pneumonia & pleurisy age >17 w/o cc 90 0.6085
Simple pneumonia & pleurisy age 0-17 91 0.6034
Interstitial lung disease w/cc 92 0.8099
Interstitial lung disease w/o cc 93 0.8099
Pneumothorax w/cc 94 1.1944
Pneumothorax w/o cc 95 0.5990
Bronchitis & asthma age >17 w/cc 96 0.5818
Bronchitis & asthma age >17 w/o cc 97 0.4555
Bronchitis & asthma age 0-17 98 0.4136
Respiratory signs & symptoms w/cc 99 0.7489
Respiratory signs & symptoms w/o cc 100 0.5718
Other respiratory system diagnoses w/cc 101 0.9166
Other respiratory system diagnoses w/o cc 102 0.4774
Heart Transplant 103 26.6896
Cardiac valve & other major cardiothoracic proc w/cardiac cath 104 6.6416
Cardiac valve & other major cardiothoracic proc w/o cardiac cath. 105
7.5681
Coronary bypass with PTCA 106 5.4454
Coronary bypass with cardiac catheter 107 4.8987
Other cardiothoracic procedures 108 5.7692
Coronary bypass w/o cardiac catheter 109 3.3968
Major reconstructive vascular proc w/cc 110 4.4736
Major reconstructive vascular proc w/o cc 111 1.8550
Purcutaneous cardiovascular procedures 112 1.5952
Amputation for circ system disorders except upper limb & toe 113 3.1441
Upper limb & toe amputation for circ system disorders 114 1.6096
Perm cardiac pacemaker implant w/AMI, heart failure or shock 115 2.9466
Oth perm cardiac pacemaker implant or PTCA with coronary art sten 116 2.0408
Cardiac pacemaker revision except device replacement 117 1.0212
Cardic pacemaker device replacement 118 1.5342
Vein ligation & stripping 119 1.5548
Other circulatory system O.R. procedure 120 2.1413
Circulatory disorders w/AMI w/C.V. comp disch alive 121 1.5370
Circulatory disorders w/AMI w/o C.V. comp disch alive 122 1.0510
Circulatory disorders w/AMI, expired 123 1.4455
Circulatory disorders except AMI, w/card cath & complex diag 124 1.3513
Circulatory disorders except AMI, w/card cath w/o comp. diag 125 0.9924
Acute & subacute endocarditis 126 2.7229
Heart failure & shock 127 0.8869
Deep vein thrombophlebitis 128 0.8616
Cardiac arrest, unexplained 129 1.3568
Peripheral vascular disorders w/cc 130 0.9077
Peripheral vascular disorders w/o cc 131 0.6423
Atherosclerosis w/cc 132 0.6814
Atherosclerosis w/o cc 133 0.5245
Hypertension 134 0.6687
Cardiac congenital & valvular disorders age > 17 w/cc 135 0.9210
Cardiac congenital & valvular disorders age > 17 w/o cc 136 0.5406
Cardiac congenital & valvular disorders age 0-17 137 2.0212
Cardiac arrhythmia & conduction disorder w/cc 138 0.8736
Cardiac arrhythmia & conduction disorder w/o cc 139 0.4664
Angina pectoris 140 0.5436
Syncope & collapse w/cc 141 0.5582
Syncope & collapse w/o cc 142 0.4954
Chest pain 143 0.5032
Other circulatory system diagnoses w/cc 144 1.2483
Other circulatory system diagnoses w/o cc 145 0.6799
Rectal resection w/cc 146 2.3799
Rectal resection w/o cc 147 1.2923
Major small & large bowel procedures w/cc 148 3.2486
Major small & large bowel procedures w/o cc 149 1.6206
Peritoneal adhesiolysis w/cc 150 2.2902
Peritoneal adhesiolysis w/o cc 151 1.1801
Minor small & large bowel procedures w/cc 152 2.1628
Minor small & large bowel procedures w/o cc 153 1.0625
Stomach, esophageal & duodenal proc age >17 w/cc 154 3.1829
Stomach, esophageal & duodenal proc age >17 w/o cc 155 1.2280
Stomach, esophageal & duodenal proc age 0-17 156 1.5749
Anal & stomal procedures w/cc 157 0.9858
Anal & stomal procedures w/o cc 158 0.6808
Hernia procedures exc inguinal & fem age >17 w/cc 159 1.1191
Hernia procedures exc inguinal & fem age >17 w/o cc 160 0.7295
Inguinal & femoral hernia procedures age >17 w/cc 161 0.8990
Inguinal & femoral hernia procedures age >17 w/o cc 162 0.7723
Hernia procedures age 0-17 163 1.2984
Appendectomy w/complicated principal diag w/cc 164 1.9349
Appendectomy w/complicated principal diag w/o cc 165 1.0931
Appendectomy w/o complicated principal diag w/cc 166 1.1133
Appendectomy w/o complicated principal diag w/o cc 167 0.6788
Mouth procedures w/cc 168 1.8110
Mouth procedures w/o cc 169 0.6892
Other digestive system O.R. procedures w/cc 170 2.2499
Other digestive system O.R. procedures w/o cc 171 1.0742
Digestive malignancy w/cc 172 1.4649
Digestive malignancy w/o cc 173 0.5409
G.I. hemorrhage w/cc 174 1.0088
G.I. hemorrhage w/o cc 175 0.4791
Complicated peptic ulcer 176 0.8837
Uncomplicated peptic ulcer w/cc 177 0.7655
Uncomplicated peptic ulcer w/o cc 178 0.5898
Inflammatory bowel disease 179 0.7177
G.I. obstruction w/cc 180 0.8280
G.I. obstruction w/o cc 181 0.5111
Esophagitis, gastroent & misc digest digest age >17 w/cc 182 0.6656
Esophagitis, gastroent & misc digest digest age >17 w/o cc 183 0.4955
Esophagitis, gastroent & misc digest digest age 0-17 184 0.5531
Dental & oral dis except extractions & rest. age >17 185 0.7829
Dental & oral dis except extractions & rest. age 0-17 186 0.5160
Dental extractions & restorations 187 1.0445
Other digestive system diagnoses age >17 w/cc 188 0.9632
Other digestive system diagnoses age >17 w/o cc 189 0.6284
Other digestive system diagnoses age 0-17 190 0.8357
Pancreas, liver & shunt procedures w/cc 191 3.4375
Pancreas, liver & shunt procedures w/o cc 192 1.4775
Biliary tract proc except only cholecyst w or w/o CDE w/cc 193
3.1504
Biliary tract proc except only cholecyst w or w/o CDE w/o cc 194 3.0931
Total cholecystectomy w/CDE w/cc 195 2.5499
Total cholecystectomy w/CDE w/o cc 196 1.5689
Total cholecystectomy w/o CDE w/cc 197 2.0852
Total cholecystectomy w/o CDE w/o cc 198 1.0921
Hepatobiliary diagnostic procedure for malignancy 199 2.2861
Hepatobiliary diagnostic procedure for nonmalignancy 200 4.3502
Other hepatobiliary or pancreas O.R. procedures 201 3.2916
Cirrhosis & alcoholic hepatitis 202 1.3476
Malignancy of hepatobiliary system or pancreas 203 1.0915
Disorders of pancreas except malignancy 204 0.9031
Disorders of liver except malig, cirr, alc, hepa w/cc 205 1.0247
Disorders of liver except malig, cirr, alc, hepa w/o cc 206 0.6363
Disorders of the biliary tract w/cc 207 0.9074
Disorders of the biliary tract w/o cc 208 0.5324
Major joint & limb reattachment procedures 209 1.8759
Hip & femur procedures except major joint age >17 w/cc 210 1.8755
Hip & femur procedures except major joint age >17 w/o cc 211 1.2735
Hip & femur procedures except major joint age 0-17 212 1.1697
Amputation for musculoskeletal system & conn tissue disorder 213 1.4829
Biopsies of musculoskeletal system & conn tissue 216 1.7962
Wnd debrid & skn grft except hand, for muscskelet & conn tis 217 2.9027
Lower extrem/humer proc except hip, foot age >17 w/cc 218 1.6326
Lower extrem/humer proc except hip, foot age >17 w/o cc 219 0.9305
Lower extrem/humer proc except hip, foot age 0-17 220 0.8260
Major shoulder/elbow proc or other upper extremity proc w/cc 223 0.7523
Shoulder, elbow or forearm proc, exc major joint proc w/o cc 224 0.6847
Foot procedures 225 1.0420
Soft tissue procedures w/cc 226 1.4131
Soft tissue procedures w/o cc 227 0.6334
Major thumb or joint proc,or oth hand/wrist w/cc 228 0.9218
Hand or wrist proc, except major joint w/o cc 229 0.7853
Local excision & removal of int fix dev hip & femur 230 0.8342
Local excision & removal of int fix dev exc hip & femur 231 1.0211
Arthroscopy 232 0.9478
Other musculoskelet sys & conn tiss O.R. w/cc 233 1.6894
Other musculoskelet sys & conn tiss O.R. w/o cc 234 1.1621
Fractures of femur 235 1.0329
Fractures of hip & pelvis 236 1.1218
Sprains, strains, & dislocations of hip 237 0.6520
Osteomyelitis 238 1.5167
Pathological fractures & musculoskeletal & conn tiss malig. 239 1.0203
Connective tissue disorders w/cc 240 1.4879
Connective tissue disorders w/o cc 241 0.6628
Septic arthritis 242 0.9691
Medical back problems 243 0.6663
Bone diseases & specific arthropathies w/cc 244 0.8676
Bone diseases & specific arthropathies w/o cc 245 0.5113
Non-specific arthropathies 246 0.4154
Signs & symptoms of musculoskeletal system & conn tissue 247 0.4867
Tendonitis, myositis & bursitis 248 0.7840
Aftercare, musculoskeletal system & connective tissue 249 0.5780
Fx, sprn, strn & disl of forearm, hand, age >17 w/cc 250 0.6614
Fx, sprn, strn & disl of forearm, hand, age >17 w/o cc 251 0.4197
Fx, sprn, strn & disl of forearm, hand, age 0-17 252 0.3957
Fx, sprn, strn & disl of uparm,lowleg ex foot age >17 w/cc 253 0.6655
Fx, sprn, strn & disl of uparm,lowleg ex foot age >17 w/o cc 254 0.4828
Fx, sprn, strn & disl of uparm, lowleg ex foot age 0-17 255 0.3783
Other musculoskeletal system & connective tissue 256 0.7369
Total mastectomy for malignancy w/cc 257 0.8963
Total mastectomy for malignancy w/o cc 258 0.7961
Subtotal mastectomy for malignancy w/cc 259 1.0885
Subtotal mastectomy for malignancy w/o cc 260 0.7899
Breast proc for non-malignancy except biopsy 261 0.8225
Breast biopsy & local excision for non-malignancy 262 1.2325
Skin graft &/or debrid for skn ulcer or cell w/cc 263 2.5994
Skin graft &/or debrid for skn ulcer or cell w/o cc 264 1.0889
Skin graft &/or debrid except for skin ulc w/cc 265 2.4134
Skin graft &/or debrid except for skin ulc w/o cc 266 1.1988
Perianal & pilonidal procedures 267 0.6962
Skin, subcutaneous tissue & breast plastic procedures 268 1.7619
Other skin, subcut tiss & breast proc w/cc 269 1.3058
Other skin, subcut tiss & breast proc w/o cc 270 0.7629
Skin ulcers 271 1.4479
Major skin disorders w/cc 272 1.0969
Major skin disorders w/o cc 273 0.7270
Malignant breast disorders w/cc 274 1.5278
Malignant breast disorders w/o cc 275 0.5043
Non-maligant breast disorders 276 0.6041
Cellulitis age >17 w/cc 277 0.8697
Cellulitis age >17 w/o cc 278 0.5483
Cellulitis age 0-17 279 0.4653
Trauma to the skin, subcut tiss/breast age >17 w/cc 280 0.5634
Trauma to the skin, subcut tiss/breast age >17 w/o cc 281 0.4042
Trauma to the skin, subcut tiss/breast age 0-17 282 0.3855
Minor skin disorders w/cc 283 0.5847
Minor skin disorders w/o cc 284 0.4949
Amputat of lower limb for endocrine, nutrit, or metab disord 285 2.0864
Adrenal & pituitary procedures 286 2.6705
Skin grafts & wound debrid for endoc, nutrit, metab disorder 287 1.5187
O.R. procedures for obesity 288 1.3541
Parathyroid procedures 289 0.8394
Thyroid procedures 290 0.8415
Thyroglossal procedures 291 0.8537
Other endocrine, nutrit & metab O.R. proc w/cc 292 2.5316
Other endocrine, nutrit & metab O.R. proc w/o cc 293 2.3357
Diabetes age >35 294 0.7742
Diabetes age 0-35 295 0.5444
Nutritional & misc metabolic disorders age >17 w/cc 296 0.8154
Nutritional & misc metabolic disorders age >17 w/o cc 297 0.5041
Nutritional & misc metabolic disorders age 0-17 298 0.5501
Inborn errors of metabolism 299 1.3613
Endocrine disorders w/cc 300 0.9791
Endocrine disorders w/o cc 301 0.4492
Kidney transplant 302 4.5328
Kidney,ureter & major bladder proc for neoplasm 303 2.7844
Kidney,ureter & major bladder proc nonneo w/cc 304 2.1522
Kidney,ureter & major bladder proc nonneo w/o cc 305 1.0125
Prostatectomy w/ cc 306 2.1876
Prostatectomy w/o cc 307 0.9156
Minor bladder procedures w/cc 308 1.3948
Minor bladder procedures w/o cc 309 0.7583
Transurethral procedures w/cc 310 0.9260
Transurethral procedures w/o cc 311 0.6246
Urethral procedures, age >17 w/cc 312 1.3987
Urethral procedures, age >17 w/o cc 313 0.6462
Urethral procedures, age 0-17 314 1.5919
Other kidney & urinary tract O.R. procedures 315 1.7155
Renal failure 316 1.1148
Admit for renal dialysis 317 0.4578
Kidney & urinary tract neoplasms w/cc 318 1.0165
Kidney & urinry tract neoplasms w/o cc 319 0.7502
Kidney & urinary tract infections age >17 w/cc 320 0.6894
Kidney & urinary tract infections age >17 w/o cc 321 0.4597
Kidney & urinary tract infections age 0-17 322 0.4759
Urinary stones w/cc, &/or esw lithotripsy 323 0.6259
Urinary stones w/o cc 324 0.4042
Kidney & urinary tract signs & symptoms age >17 w/cc 325 0.4845
Kidney & urinary tract signs & symptoms age >17 w/o cc 326 0.4301
Kidney & urinary tract signs & symptoms age 0-17 327 0.3394
Urethral stricture age >17 w/cc 328 0.6827
Urethral stricture age >17 w/o cc 329 0.5309
Urethral stricture age 0-17 330 0.5489
Other kidney & urinary tract diagnoses age >17 w/cc 331 0.9216
Other kidney & urinary tract diagnoses age >17 w/o cc 332 0.5224
Other kidney & urinary tract diagnoses age 0-17 333 0.8528
Major male pelvic procedures w/cc 334 1.2990
Major male pelvic procedures w/o cc 335 1.0163
Transurethral prostatectomy w/cc 336 0.9574
Transurethral prostatectomy w/o cc 337 0.4984
Testes procedures, for malignancy 338 2.1979
Testes procedures, non-malignancy age >17 339 1.1909
Testes procedures, non-malignancy age 0-17 340 0.4802
Penis procedures 341 0.7790
Circumcision age >17 342 0.7740
Circumcision age 0-17 343 0.1490
Other male reproductive system O.R. proc malignancy 344 1.9050
Other male reproductive system O.R. proc exc malignancy 345 1.2703
Malignancy, male reproductive system, w/cc 346 2.0642
Malignancy, male reproductive system w/o cc 347 0.5214
Benign prostatic hypertrophy w/cc 348 0.7007
Benign prostatic hypertrophy w/o cc 349 0.4524
Inflammation of the male reproductive system 350 0.5011
Sterilization, male 351 0.3772
Other male reproductive system diagnoses 352 1.3390
Pelvic evisceration, radical hysterectomy 353 1.6632
Uterine,adnexa proc for non-ovarian/adn w/cc 354 1.5455
Uterine,adnexa proc for non-ovarian/adn w/o cc 355 0.7025
Female reproductive system reconstructive proc 356 0.6387
Uterine & adnexa proc for ovarian or ad 357 2.0812
Uterine & adnexa proc for non-malignanc w/cc 358 0.9942
Uterine & adnexa proc for non-malignanc w/o cc 359 0.7717
Vagina, cervix & vulva procedures 360 0.6328
Laparoscopy & incisional tubal interruption 361 0.7715
Endoscopic tubal interruption 362 0.5952
D&C, conization & radio-implant, for malignancy 363 0.9501
D&C, conization except for malignancy 364 0.8207
Other female reproductive system O.R. procedures 365 1.3508
Malignancy, female reproductive system w/cc 366 0.7947
Malignancy, female reproductive system w/o cc 367 0.4822
Infections, female reproductive system 368 0.4901
Menstrual & other female reproductive system 369 0.4683
Cesarean section w/cc 370 1.0165
Cesarean section w/o cc 371 0.8138
Vaginal delivery w/complicating diagnoses 372 0.5972
Vaginal delivery w/o complicating diagnoses 373 0.4337
Vaginal delivery w/sterilization &/or D&C 374 0.7509
Vaginal delivery w/O.R. proc except sterial D&C 375 1.0444
Postpartum & post abortion diagnoses w/o O.R. procedure 376 0.4791
Postpartum & post abortion diagnoses w/O.R. procedure 377 0.9947
Ectopic pregnancy 378 0.7504
Threatened abortion 379 0.6333
Abortion w/o D&C 380 0.3491
Abortion w/D&C, aspiration curettage or hystorectomy 381 0.6092
False labor 382 0.3575
Other antepartum diagnoses w/medical complications 383 0.5227
Other antepartum diagnoses w/o medical complications 384 0.4998
Splenectomy age >17 392 2.6258
Splenectomy age 0-17 393 1.2027
Other O.R. procedures of the blood and organs 394 1.7582
Red blood cell disorders age >17 395 0.6369
Red blood cell disorders age 0-17 396 0.7586
Coagulation disorders 397 1.3271
Reticuloendothelial & immunity disorder w/cc 398 1.4179
Reticuloendothelial & immunity disorder w/o cc 399 0.5035
Lymphoma & leukemia w/major O.R. procedure 400 2.5202
Lymphoma & non-acute leukemia w/other w/cc 401 2.6982
Lymphoma & non-acute leukemia w/other w/o cc 402 1.3352
Lymphoma & non-acute leukemia w/cc 403 2.0407
Lymphoma & non-acute leukemia w/o cc 404 0.7832
Acute leukemia w/o major O.R. procedure 405 3.5715
Myeloprolif disord or poorly diff neopl w/cc 406 2.4288
Myeloprolif disord or poorly diff neopl w/o cc 407 1.3412
Myeloprolif disord or poorly diff neopl w/other O.R. proc 408 2.6709
Radiotherapy 409 0.5504
Chemotherapy 410 0.7436
History of malignancy w/o endoscopy 411 0.7829
History of malignancy w/endoscopy 412 0.5301
Other myeloprolif dis or poorly diff neopl diag w/cc 413 1.5482
Other myeloprolif dis or poorly diff neople diag w/o cc 414 0.5749
O.R. procedure for infectious & parasitic disease 415 3.4231
Septicemia age >17 416 1.3465
Septicemia age 0-17 417 1.3871
Postoperative & post-traumatic infections 418 0.8072
Fever of unknown origin age >17 w/cc 419 1.0334
Fever of unknown origin age >17 w/o cc 420 0.6397
Viral illness age >17 421 0.5114
Viral illness & fever of unknown origin 422 0.4529
Other infectious & parasitic diseases diagnoses 423 2.1485
Alcohol/drug abuse or dependence, left AMA 433 0.4280
Alc/drug abuse or depend, detox or oth sympt treat w/cc 434 0.6162
Alc/drug abuse or depend, detox or oth sympt treat w/o cc 435 0.4469
Alc/drug dependence w/rehabilitation therapy 436 1.4334
Alc/drug dependence, combined rehab & detox therapy 437 0.8769
Skin grafts for injuries 439 1.5934
Wound debridements for injuries 440 1.4537
Hand procedures for injuries 441 1.0203
Other O.R. procedures for injuries w/cc 442 1.9396
Other O.R. procedures for injuries w/o cc 443 0.7947
Multiple trauma age >17 w/cc 444 0.6886
Multiple trauma age >17 w/o cc 445 0.5800
Multiple trauma age 0-17 446 0.4677
Allergic reactions age >17 447 0.3914
Allergic reactions age 0-17 448 0.2476
Poisoning & toxic effects of drugs age >17 w/cc 449 0.7695
Poisoning & toxic effects of drugs age >17 w/o cc 450 0.5019
Poisoning & toxic effects of drugs age 0-17 451 0.5137
Complications of treatment w/cc 452 0.8909
Complications of treatment w/o cc 453 0.5154
Other injury, poisoning & toxic effect w/cc 454 1.2850
Other injury, poisoning & toxic effect w/o cc 455 0.5871
O.R. proc w/diagnoses of other contact w/health services 461 1.6177
Rehabilitation 462 3.1686
Signs & symptoms w/cc 463 0.6242
Signs & symptoms w/o cc 464 0.4352
Aftercare w/history of malignancy as second diagnosis 465 0.2567
Aftercare w/o history of malignancy as second diagnosis 466 1.2175
Other factors influencing health status 467 0.6322
Extensive O.R. procedure unrelated to principal diagnosis 468 2.8620
Bilateral or multiple major joint procs of lower extremity 471 3.0724
Acute leukemia w/o major O.R. procedure age >17 473 5.4459
Respiratory system diagnosis w/ventilator support 475 4.1483
Prostatic O.R. procedure unrelated to principal diagnosis 476 2.2449
Non-extensive O.R. procedure unrelated to prin diagnosis 477 1.7031
Other vascular procedures w/cc 478 2.2137
Other vascular procedures w/o cc 479 1.6658
Liver Transplant 480 8.4796
Bone Marrow Transplant 481 13.1097
Tracheostomy for face, mouth & neck diagnoses 482 3.6102
Tracheostomy except for face, mouth & neck diagnoses 483 13.5419
Craniotomy for multiple significant trauma 484 8.3395
Limb reattachment, hip and femur proc for mult. sig. trauma 485 3.9866
Other O.R. procedures for multiple significant trauma 486 5.4134
Other multiple significant trauma 487 2.2973
HIV w/extensive O.R. procedure 488 2.7945
HIV w/major related condition 489 1.5278
HIV w/ or w/o other related condition 490 0.8156
Major joint & limb reattachment procures of upper extremity 491 1.4051
Chemotherapy w/acute leukemia 492 1.2406
Laparoscopic cholecystectomy w/cc 493 1.3975
Laparoscopic cholecystectomy w/o cc 494 0.9379
Lung Transplant 495 30.6689
Combined Anterioir/Posterior Spinal Fusion. 496 3.4928
Spinal Fusion w/cc (Eff 7/98, replaces 214-215). 497 2.7000
Spinal Fusion w/o cc (Eff 7/98, replaces 214-215). 498 1.4940
Back & neck procs except spinal fusion w/ cc. 499 1.1991
Back & neck procs except spinal fusion w/o cc. 500 0.7895
Knee proc w PDX of infection w/ cc. 501 1.6465
Knee proc w PDX of infection w/o cc. 502 1.6465
Knee procedures w/o PDX of infection. 503 0.9743
Extensive 3rd degree burn with skin graft. 504 17.0864
Extensive 3rd degree burn without skin graft. 505 5.0463
Full thickness burn with skin graft or inhal injury with CC or sig trauma 506 9.5467
Full thickness burn with skin graft or inhal injury w/o CC or sig trauma 507 3.2850
Full thickness burn w/o skin graft or inhal injury with CC or sig trauma 508 1.5418
Full thickness burn w/o skin graft or inhal injury w/o CC or sig trauma 509
1.0147
Nonextensive burns with CC or significant trauma. 510 1.6614
Nonextensive burns without CC or significant trauma. 511 1.0559
DRG groupings for Wisconsin Medicaid for Newborns & Other Neonates with Conditions Originating in Perinatal Period
Died w/in one day, same hosp 601 0.1666
Died w/in one day, recv hosp 602 0.6032
Transferred w/in 4 days 604 0.2453
Less than 750 grams - discharged dead 610 6.4138
Less than 750 grams - discharged alive 614 17.9136
Less than 1000 grams - discharged dead 620 7.2985
Less than 1000 grams - discharged alive 624 13.8971
Less than 1500 grams - discharged dead 637 5.2500
Less than 1500 grams - O.R. performed 638 12.7784
Less than 1500 grams - no O.R. performed 639 7.4036
Less than 2000 grams - O.R. excl circumcision 648 7.3321
Less than 2000 grams - no O.R. performed 649 2.6899
Less than 2500 grams - O.R. performed 650 8.8796
Less than 2500 grams - no O.R.- major dx prob 656 1.6674
Less than 2500 grams - no O.R.- minor dx prob 657 0.5172
Less than 2500 grams - no O.R.- no dx prob 670 2.1160
2500 and greater grams - no O.R.- major dx prob 676 0.8128
2500 and greater grams - no O.R.- minor dx prob 677 0.2325
2500 and greater grams - no O.R.- no dx prob 678 0.1486
2500 and greater grams - O.R. performed 680 4.3051
DRG groupings for Wisconsin Medicaid for MENTAL DISEASE AND DISORDER
Milwaukee County Mental Health Center (MCMHC)
17 & younger All OR Procedures 701 4.5739
Over 17 -- All OR Procedures 702 4.5845
17 & younger -- Adjust. Reaction or Dysf. 703 2.8821
Over 17 -- Adjust. Reaction or Dysf. 704 1.2524
17 & younger -- Depressive Neurosis 705 0.9622
Over 17 -- Depressive Neurosis 706 1.1298
17 & younger ? Nondepressive Neurosis 707 1.5491
Over 17 -- Nondepressive Neurosis 708 1.3048
17 & younger -- Personality Disorders 709 3.1015
Over 17 -- Personality Disorders 710 1.5308
17 & younger -- Organic Disturbances 711 4.5530
Over 17 -- Organic Disturbances 712 2.3601
17 & younger -- Psychoses 713 2.3330
Over 17 -- Psychoses 714 1.8706
17 & younger -- Childhood Disorders 715 3.1794
Over 17 -- Childhood Disorders 716 1.7638
17 & younger -- Other Mental Disorders 717 6.4485
Over 17 -- Other Mental Disorders 718 1.9670
Hospital Institutions for Mental Disease (IMD)
17 & younger -- All OR Procedures 721/821 2.4758
Over 17 -- All OR Procedures 722/822 2.4815
17 & younger -- Adjust. Reaction or Dysf. 723/823 1.5601
Over 17 -- Adjust. Reaction or Dysf. 724/824 0.6779
17 & younger -- Depressive Neurosis 725/825 1.0539
Over 17 -- Depressive Neurosis 726/826 0.6116
17 & younger -- Nondepresive Neurosis 727/827 0.7048
Over 17 -- Nondepresive Neurosis 728/828 0.4493
17 & younger -- Personality Disorders 729/829 1.1771
Over 17 -- Personality Disorders 730/830 0.8286
17 & younger -- Organic Disturbances 731/831 2.4645
Over 17 -- Organic Disturbances 732/832 1.2775
17 & younger -- Psychoses 733/833 1.2105
Over 17 -- Psychoses 734/834 1.1903
17 & younger -- Childhood Disorders 735/835 1.0749
Over 17 -- Childhood Disorders 736/836 0.9547
17 & younger -- Other Mental Disorders 737/837 3.4905
Over 17 -- Other Mental Disorders 738/838 1.0647
Acute Care Hospitals With Exempt Psych Units
17 & younger -- All OR Procedures 741/841 1.9311
Over 17 -- All OR Procedures 742/842 1.9355
17 & younger -- Adjust. Reaction or Dysf. 743/843 1.2168
Over 17 -- Adjust. Reaction or Dysf. 744/844 0.6549
17 & younger -- Depressive Neurosis 745/845 0.8261
Over 17 -- Depressive Neurosis 746/846 0.5693
17 & younger -- Nondepresive Neurosis 747/847 0.7519
Over 17 -- Nondepresive Neurosis 748/848 0.7012
17 & younger -- Personality Disorders 749/849 2.0761
Over 17 -- Personality Disorders 750/850 0.7445
17 & younger -- Organic Disturbances 751/851 1.9222
Over 17 -- Organic Disturbances 752/852 1.2212
17 & younger -- Psychoses 753/853 1.5944
Over 17 -- Psychoses 754/854 0.9113
17 & younger -- Childhood Disorders 755/855 1.2898
Over 17 -- Childhood Disorders 756/856 0.8764
17 & younger -- Other Mental Disorders 757/857 2.7225
Over 17 -- Other Mental Disorders 758/858 0.8305
Acute Care Hospitals Without Exempt Psych Units
17 & younger -- All OR Procedures 761/861 1.7197
Over 17 -- All OR Procedures 762/862 1.7236
17 & younger -- Adjust. Reaction or Dysf. 763/863 1.0836
Over 17 -- Adjust. Reaction or Dysf. 764/864 0.5871
17 & younger -- Depressive Neurosis 765/865 0.7019
Over 17 -- Depressive Neurosis 766/866 0.5584
17 & younger -- Nondepresive Neurosis 767/867 0.7202
Over 17 -- Nondepresive Neurosis 768/868 0.6481
17 & younger -- Personality Disorders 769/869 1.1661
Over 17 -- Personality Disorders 770/870 0.5755
17 & younger -- Organic Disturbances 771/871 1.7118
Over 17 -- Organic Disturbances 772/872 0.8873
17 & younger -- Psychoses 773/873 1.3194
Over 17 -- Psychoses 774/874 0.9113
17 & younger -- Childhood Disorders 775/875 1.1485
Over 17 -- Childhood Disorders 776/876 0.6631
17 & younger -- Other Mental Disorders 777/877 2.4244
Over 17 -- Other Mental Disorders 778/878 0.7395
SPECIAL TRANSPLANT DRG Groupings for Wisconsin Medicaid
Heart/Lung Transplant 990 74.2040
Pancreas Transplant 991 3.5163
