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Ohio Laws and Rules
(A) Payments under the prospective payment system. For inpatient hospitals subject to prospective payment as described in rule 5101:3-2-07.1 of the Administrative Code, payments are made on the basis of a prospectively determined rate as provided in rule 5101:3-2-07.4 of the Administrative Code. Additional payments may be made for services described in accordance with paragraph (C) of rule 5101:3-2-07.1 of the Administrative Code. The amount paid represents final payment based on a submission of a discharge bill. No year-end retrospective adjustment is made for prospective payment except as provided in rules 5101:3-2-07.8 and 5101:3-2-24 of the Administrative Code. Except as provided in rules 5101:3-2-24, 5101:3-2-07.13, and 5101:3-2-42 of the Administrative Code, a hospital may keep the difference between its prospective payment rate and costs incurred in furnishing inpatient services and is at risk for costs which exceed the prospective payment amounts.
(B) Amounts of payment, including all components of the prospective payment rate, DRG categories and relative weights associated with such categories, identification of outlier cases and payment methods for outliers, transfers and readmissions, and other provisions affecting amounts of payment are based on applying the provisions of this chapter to claims associated with dates of discharge on or after the effective dates of the rules in this chapter, unless otherwise specified.
(C) Hospitals must submit a claim for payment only upon a recipient’s final discharge as defined in rule 5101:3-2-02 of the Administrative Code including those discharges which meet the criteria for outlier payments defined in rule 5101:3-2-07.9 of the Administrative Code unless the claim qualifies for interim billing as described in paragraph (C)(3) of this rule. Transfers and readmissions are defined and paid in accordance with the provisions of this rule. The department shall assign a DRG by using the DRG “grouper,” modified as described in this paragraph. For discharges on or after February 1, 2000, the department uses the “grouper” distributed by “Health Services, Incorporated,” a software package used by medicare during federal fiscal year 1998. A listing of DRG classifications is shown in appendix A of this rule. The relative weights assigned are those described in rule 5101:3-2-07.3 of the Administrative Code. Cases which would be classified in DRG 385 or DRG 456 because of a transfer or death, but which involve a length of stay greater than fifteen days, are classified in the DRG which is otherwise appropriate if the transfer or death is not considered. For cases classified into DRG 386, two subgroups are created based upon the ICD-9-CM code. One subgroup is determined by cases which have ICD-9-CM code 765.0 listed as one of its diagnoses. The second subgroup is comprised of those cases that are grouped into DRG 386, but do not have 765.0 listed as a diagnosis. In accordance with rule 5101:3-2-07.3 of the Administrative Code, different relative weights are assigned to the second DRG 386 subgroup depending on whether one, the hospital operates a level I or level II nursery, or two, a level III nursery. For cases classified into DRG 387, two subgroups are created based upon birthweight. Infants with weights of zero to one thousand seven hundred fifty grams are grouped into one subgroup and infants with weights of one thousand seven hundred fifty-one grams and above are grouped into another subgroup. In accordance with rule 5101:3-2-07.3 of the Administrative Code, different relative weights are assigned to each DRG 387 subgroup depending on whether one, the hospital operates a level I or II nursery, or two, a level III nursery. Prior to submitting a claim to the DRG “Grouper,” each claim will be submitted to the medicare clinical editor to ensure that the information on the claim is complete and consistent . Each discharge will be assigned to only one DRG regardless of the number of conditions treated or services furnished by a hospital, except as provided in paragraph (C)(1) of this rule.
(1) For inpatient services provided to patients who are discharged, within the same hospital, from an acute care bed and admitted to a bed in a psychiatric unit distinct part, payment will be made based on the DRG representing services provided in the acute care section and the services provided in the psychiatric unit distinct part if the services are assigned to DRGs 425 to 435. If the services provided in both the acute care section and the psychiatric unit distinct part are assigned to any combination of DRGs 425 to 435, payment will be made only for that DRG assigned as a result of the information on a claim submitted by the hospital for services provided from the date of admission to the hospital through the date of discharge or transfer from the hospital. If separate claims are submitted for any combination of DRGs 425 to 435, only the first claim processed will be paid. In order to receive payment for the entire period of hospitalization, the hospital will need to submit an adjustment claim reflecting services and charges for the entire hospitalization.
In accordance with rule 5101:3-2-03 of the Administrative Code, no coverage is available for days of inpatient care which occur solely for the provision of rehabilitation services related to a chemical dependency. Therefore, ICD-9-CM procedure codes which must be present for a claim to group to either DRG 436 or 437, will not be submitted to the DRG “grouper.”
(2) For claims with discharge dates after September 3, 1991 which are rejected by the clinical editor as a result of an age, diagnosis code conflict, and the accuracy of the information contained on the claim is confirmed by the hospital, the prospective payment amount will be eighty-five per cent of the product of allowed claim charges times the hospital-specific, medicaid inpatient cost-to-charge ratio as described in paragraph (B)(2) of rule 5101:3-2-22 of the Administrative Code.
(3) A claim for inpatient services qualifies for interim payment on the thirtieth day of a consecutive inpatient stay and at thirty-day intervals thereafter. Under interim payment, hospitals will be paid on a percentage basis of charges. The percentage will represent the hospital-specific cost-to-charge ratio as described in paragraph (B)(2) of rule 5101:3-2-22 of the Administrative Code. For those hospitals which are not required to file a cost report under the provisions of rule 5101:3-2-23 of the Administrative Code, the statewide average inpatient cost-to-charge ratio as described in paragraph (B)(2) of rule 5101:3-2-22 of the Administrative Code will be used. Interim payments are made as a credit against final payment of the final discharge bill. Amounts of difference between interim payment made and the prospective payment described in paragraph (A) of this rule for the final discharge will be reconciled when the final discharge bill is processed.
(D) Payments for transfers as defined in rule 5101:3-2-02 of the Administrative Code are subject to the provisions of paragraphs (D)(1) and (D)(2) of this rule.
(1) Payment to the transferring hospital. If a hospital paid under the prospective payment system transfers an inpatient to another hospital and that transfer is appropriate as defined in rule 5101:3-2-07.13 of the Administrative Code, then the transferring hospital is paid a per diem rate for each day of the patient’s stay in that hospital, plus capital and teaching allowances, as applicable, not to exceed, for nonoutlier cases, the final prospective payment rate that would have been paid for the appropriate DRG as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code, except when that case is grouped into DRG 385 or DRG 456. Cases which are grouped into DRG 385 or DRG 456 are paid the full DRG payment in accordance with rule 5101:3-2-07.4 of the Administrative Code. Except for DRG 385 and DRG 456, when a patient is transferred, the department’s payment is based on the DRG under which the patient was treated at each hospital. The per diem rate is determined by dividing the product of the hospital’s adjusted inflated average cost per discharge multiplied by the DRG relative weight as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code by the statewide geometric mean length of stay calculated excluding outliers for the specific DRG as described in rule 5101:3-2-07.3 of the Administrative Code into which the case falls.
(2) Payment to the discharging hospital. A hospital which receives a transfer and subsequently discharges that individual (as defined in rule 5101:3-2-02 of the Administrative Code) is paid a per diem rate for each day of the patient’s stay in that hospital, plus capital and teaching allowances, as applicable, not to exceed, for nonoutlier cases, the final prospective payment rate amount that would have been paid for the appropriate DRG as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code. When a patient is transferred, the department’s payment is based on the DRG under which the patient was treated at each hospital. The per diem rate is determined by dividing the product of the hospital’s adjusted inflated average cost per discharge multiplied by the DRG relative weight as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code by the geometric mean length of stay calculated excluding outliers for the specific DRG as described in rule 5101:3-2-07.3 of the Administrative Code into which the case falls.
(E) Outlier payments. In addition to the payment provisions described in this rule, any hospital that is involved in discharging or transferring a patient as defined in rule 5101:3-2-02 of the Administrative Code or that provides services to a medicaid patient who is partially eligible as described in paragraph (K) of this rule may qualify for additional payments in the form of outlier payments as described in rule 5101:3-2-07.9 of the Administrative Code.
(F) Readmissions are defined in rule 5101:3-2-02 of the Administrative Code. A readmission within one calendar day of discharge, to the same institution, is considered to be one discharge for payment purposes so that one DRG payment is made. If two claims are submitted, the second claim processed will be rejected. In order to receive payment for the entire period of hospitalization, the hospital will need to submit an adjustment claim reflecting services and charges for the entire hospitalization.
(G) Claims for payment for inpatient hospital services must be submitted on the UB-92 as provided in rule 5101:3-2-02 of the Administrative Code and include the data essential to assignment of a DRG. Claims assigned to DRGs 469, and 470 will be denied due to ungroupable coding.
(H) Claims for payment for discharges that may qualify for outlier payment may be billed only after discharge unless the claim qualifies for interim billing as described in paragraph (C)(3) of this rule. The claim will be processed for payment of the appropriate DRG prospective discharge payment rate as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code and outlier payments as described in rule 5101:3-2-07.9 of the Administrative Code.
(I) Providers must submit a new claim with a copy of the remittance statement and a completed adjustment request form as described in rule 5101:3-1-19.3 of the Administrative Code in order to adjust any claim which results in an improper assignment of a DRG or to correct any information provided.
(J) In the case of deliveries, the department requires hospitals to submit separate UB-92 invoices based respectively on the mother’s individual eligibility and the child’s individual eligibility.
(K) In instances when a recipient’s eligibility begins after the date of admission to the hospital or is terminated during the course of a hospitalization, payment will be made on a per diem basis plus the allowance for capital and teaching, as applicable. The per diem payment will be determined by dividing the product of the hospital’s adjusted inflated average cost per discharge multiplied by the DRG relative weight for the DRG as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code by the statewide geometric mean length of stay calculated excluding outliers for that DRG as described in rule 5101:3-2-07.3 of the Administrative Code. The per diem amount will be multiplied times the number of covered days for which the patient was medicaid-eligible during the hospitalization. Payment for a nonoutlier case cannot exceed the final prospective payment rate for the DRG as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code.
HISTORY: Eff 10-1-84; 7-1-85; 7-3-86; 10-19-87; 6-30-89 (Emer.); 7-21-89; 7-1-90; 9-3-91 (Emer.); 11-10-91; 7-1-92; 1-20-95; 2-1-00; 8-1-02; 6-1-04
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01, 5111.02
R.C. 119.032 review dates: 03/12/2004 and 06/01/2009
Appendix A Diagnosis Related Groups, Version 15.0
001,MDC 01P,craniotomy age greater than 17 except for trauma
002,MDC 01P,craniotomy for trauma age greater than 17
003,MDC 01P,craniotomy age 0-17
004,MDC 01P,spinal procedures
005,MDC 01P,extracranial vascular procedures
006,MDC 01P,carpal tunnel release
007,MDC 01P,periph & cranial nerve & other nerv syst proc W CC
008,MDC 01P,periph & cranial nerve & other nerv syst proc W/O CC
009,MDC 01M,spinal disorders & injuries
010,MDC 01M,nervous system neoplasms W CC
011,MDC 01M,nervous system neoplasms W/O CC
012,MDC 01M,degenerative nervous system disorders
013,MDC 01M,multiple sclerosis & cerebellar ataxia
014,MDC 01M,specific cerebrovascular disorders except tia
015,MDC 01M,transient ischemic attack & precerebral occlusions
016,MDC 01M,nonspecific cerebrovascular disorders W CC
017,MDC 01M,nonspecific cerebrovascular disorders W/O CC
018,MDC 01M,cranial & peripheral nerve disorders W CC
019,MDC 01M,cranial & peripheral nerve disorders W/O CC
020,MDC 01M,nervous system infection except viral meningitis
021,MDC 01M,viral meningitis
022,MDC 01M,hypertensive encephalopathy
023,MDC 01M,nontraumatic stupor & coma
024,MDC 01M,seizure & headache age> 17 W CC
025,MDC 01M,seizure & headache age> 17 W/O CC
026,MDC 01M,seizure & headache age 0-17
027,MDC 01M,traumatic stupor & coma, coma>1 HR
028,MDC 01M,traumatic stupor & coma, coma>1 HR age>17 W CC
029,MDC 01M,traumatic stupor & coma, coma>1 HR age>17 W/O CC
030,MDC 01M,traumatic stupor & coma, coma<<1 HR age 0-17
031,MDC 01M,concussion age> 17 W CC
032,MDC 01M,concussion age> 17 W/O CC
033,MDC 01M,concussion age 0-17
034,MDC 01M,other disorders of nervous system W CC
035,MDC 01M,Other disorders of nervous system W/O CC
036,MDC 02P,Retinal procedures
037,MDC 02P,Orbital procedures
038,MDC 02P,Primary IRIS procedures
039,MDC 02P,Lens procedures with or without vitrectomy
040,MDC 02P,Extraocular procedures except orbit age>17
041,MDC 02P,Extraocular procedures except orbit age 0-17
042,MDC 02P,Intraocular procedures except retina, iris & lens
043,MDC 02M,Hyphema
044,MDC 02M,Acute major eye infections
045,MDC 02M,Neurological eye disorders
046,MDC 02M,Other disorders of the eye age> 17 W CC
047,MDC 02M,Other disorders of the eye age> 17 W/O CC
048,MDC 02M,Other disorders of the eye age 0-17
049,MDC 03P,Major head & neck procedures
050,MDC 03P,Sialoadenectomy
051,MDC 03P,Salivary gland procedures except sialoadenectomy
052,MDC 03P,Cleft lip & palate repair
053,MDC 03P,Sinus & mastoid procedures age>17
054,MDC 03P,Sinus & mastoid procedures age 0-17
055,MDC 03P,Miscellaneous ear, nose, mouth & throat procedures
056,MDC 03P,Rhinoplasty
057,MDC 03P,T&A proc, Except tonsillectomy &/or adenoidectomy only, age>17
058,MDC 03P,T&A proc, Except tonsillectomy &/or adenoidectomy only, age 0-17
059,MDC 03P,Tonsillectomy &/or adenoidectomy only, age>17
060,MDC 03P,Tonsillectomy &/or adenoidectomy only, age 0-17
061,MDC 03P,Myringotomy W tube insertion age>17
062,MDC 03P,Myringotomy W tube insertion age 0-17
063,MDC 03P,Other ear, nose, mouth & throat O.R. procedures
064,MDC 03M,Ear, nose, mouth & throat malignancy
065,MDC 03M,Dysequilibrium
066,MDC 03M,Epistaxis
067,MDC 03M,Epiglottitis
068,MDC 03M,Otitis media & URI age>17 W CC
069,MDC 03M,Otitis media & URI age>17 W/O CC
070,MDC 03M,Otitis media & URI age 0-17
071,MDC 03M,Laryngotracheitis
072,MDC 03M,Nasal trauma & deformity
073,MDC 03M,Other ear, nose, mouth & throat diagnoses age>17
074,MDC 03M,Other ear, nose, mouth & throat diagnoses age 0-17
075,MDC 04P,Major chest procedures
076,MDC 04P,Other resp system O.R. procedures W CC
077,MDC 04P,Other resp system O.R. procedures W/O CC
078,MDC 04M,Pulmonary embolism
079,MDC 04M,Respiratory infections & inflammations age>17 W CC
080,MDC 04M,Respiratory infections & inflammations age>17 W/O CC
081,MDC 04M,Respiratory infections & inflammations age 0-17
082,MDC 04M,Respiratory neoplasms
083,MDC 04M,Major chest trauma W CC
084,MDC 04M,Major chest trauma W/O CC
085,MDC 04M,Pleural effusion W CC
086,MDC 04M,Pleural effusion W/O CC
087,MDC 04M,Pulmonary edema & respiratory failure
088,MDC 04M,Chronic obstructive pulmonary disease
089,MDC 04M,Simple pneumonia & pleurisy age>17 W CC
090,MDC 04M,Simple pneumonia & pleurisy age>17 W/O CC
091,MDC 04M,Simple pneumonia & pleurisy age 0-17
092,MDC 04M,Interstitial lung disease W CC
093,MDC 04M,Interstitial lung disease W/O CC
094,MDC 04M,Pneumothorax W CC
095,MDC 04M,Pneumothorax W/O CC
096,MDC 04M,Bronchitis & asthma age>17 W CC
097,MDC 04M,Bronchitis & asthma age>17 W/O CC
098,MDC 04M,Bronchitis & asthma age 0-17
099,MDC 04M,Respiratory signs & symptoms W CC
100,MDC 04M,Respiratory signs & symptoms W/O CC
101,MDC 04M,other respiratory system diagnoses W CC
102,MDC 04M,other respiratory system diagnoses W/O CC
103,MDC 05P,heart transplant
104,MDC 05P,cardiac valve procedures W cardiac cath
105,MDC 05P,cardiac valve procedures W/O cardiac cath
106,MDC 05P,coronary bypass W cardiac cath
107,MDC 05P,coronary bypass W/O cardiac cath
108,MDC 05P,other cardiothoracic procedures
110,MDC 05P,major cardiovascular procedures W CC
111,MDC 05P,major cardiovascular procedures W/O CC
112,MDC 05P,percutaneous cardiovascular procedures
113,MDC 05P,amputation for circ system disorders except upper limb & toe
114,MDC 05P,upper limb & toe amputation for circ system disorders
115,MDC 05P,prm card pacem impl W ami,hrt fail or shk,or aicd lead or gnrtr proc
116,MDC 05P,oth perm card pacemak impl or ptca W coronary artery stent implnt
117,MDC 05P,cardiac pacemaker revision except device replacement
118,MDC 05P,cardiac pacemaker device replacement
119,MDC 05P,vein ligation & stripping
120,MDC 05P,other circulatory system O.R. procedures
121,MDC 05M,circulatory disorders W ami & major comp, discharged alive
122,MDC 05M,circulatory disorders W ami W/O major comp, discharged alive
123,MDC 05M,circulatory disorders W ami, expired
124,MDC 05M,circulatory disorders except ami, W card cath & complex diag
125,MDC 05M,circulatory disorders except ami, W card cath W/O complex diag
126,MDC 05M,acute & subacute endocarditis
127,MDC 05M,heart failure & shock
128,MDC 05M,deep vein thrombophlebitis
129,MDC 05M,cardiac arrest, unexplained
130,MDC 05M,peripheral vascular disorders W CC
131,MDC 05M,peripheral vascular disorders W/O CC
132,MDC 05M,atherosclerosis W CC
133,MDC 05M,atherosclerosis W/O CC
134,MDC 05M,hypertension
135,MDC 05M,cardiac congenital & valvular disorders age>17 W CC
136,MDC 05M,cardiac congenital & valvular disorders age>17 W/O CC
137,MDC 05M,cardiac congenital & valvular disorders age 0-17
138,MDC 05M,cardiac arrhythmia & conduction disorders W CC
139,MDC 05M,cardiac arrhythmia & conduction disorders W/O CC
140,MDC 05M,angina pectoris
141,MDC 05M,syncope & collapse W CC
142,MDC 05M,syncope & collapse W/O CC
143,MDC 05M,chest pain
144,MDC 05M,other circulatory system diagnoses W CC
145,MDC 05M,other circulatory system diagnoses W/O CC
146,MDC 06P,rectal resection W CC
147,MDC 06P,rectal resection W/O CC
148,MDC 06P,major small & large bowel procedures W CC
149,MDC 06P,major small & large bowel procedures W/O CC
150,MDC 06P,peritoneal adhesiolysis W CC
151,MDC 06P,peritoneal adhesiolysis W/O CC
152,MDC 06P,minor small & large bowel procedures W CC
153,MDC 06P,minor small & large bowel procedures W/O CC
154,MDC 06P,stomach, esophageal & duodenal procedures age>17 W CC
155,MDC 06P,stomach, esophageal & duodenal procedures age>17 W/O CC
156,MDC 06P,stomach, esophageal & duodenal procedures age 0-17
157,MDC 06P,anal & stomal procedures W CC
158,MDC 06P,anal & stomal procedures W/O CC
159,MDC 06P,hernia procedures except inguinal & femoral age>17 W CC
160,MDC 06P,hernia procedures except inguinal & femoral age>17 W/O CC
161,MDC 06P,inguinal & femoral hernia procedures age>17 W CC
162,MDC 06P,inguinal & femoral hernia procedures age>17 W/O CC
163,MDC 06P,hernia procedures age 0-17
164,MDC 06P,appendectomy W complicated principal diag W CC
165,MDC 06P,appendectomy W complicated principal diag W/O CC
166,MDC 06P,appendectomy W/O complicated principal diag W CC
167,MDC 06P,appendectomy W/O complicated principal diag W/O CC
168,MDC 03P,Mouth Procedures W CC
169,MDC 03P,Mouth Procedures W/O CC
170,MDC 06P,other digestive system O.R. procedures W CC
171,MDC 06P,other digestive system O.R. procedures W/O CC
172,MDC 06M,digestive malignancy W CC
173,MDC 06M,digestive malignancy W/O CC
174,MDC 06M,G.I. Hemorrhage W CC
175,MDC 06M,G.I. Hemorrhage W/O CC
176,MDC 06M,Complicated Peptic Ulcer
177,MDC 06M,Uncomplicated Peptic Ulcer W CC
178,MDC 06M,Uncomplicated Peptic Ulcer W/O CC
179,MDC 06M,Inflammatory Bowel Disease
180,MDC 06M,G.I. Obstruction W CC
181,MDC 06M,G.I. Obstruction W/O CC
182,MDC 06M,Esophagitis, gastroent & misc digest disorders age>17 W CC
183,MDC 06M,Esophagitis, gastroent & misc digest disorders age>17 W/O CC
184,MDC 06M,Esophagitis, gastroent & misc digest disorders age 0-17
185,MDC 03M,Dental & oral dis except extractions & restorations, age>17
186,MDC 03M,Dental & oral dis except extractions & restorations, age 0-17
187,MDC 03M,Dental extractions & restorations
188,MDC 06M,Other digestive system diagnoses age>17 W CC
189,MDC 06M,Other digestive system diagnoses age>17 W/O CC
190,MDC 06M,Other digestive system diagnoses age 0-17
191,MDC 07P,Pancreas, liver & shunt procedures W CC
192,MDC 07P,Pancreas, liver & shunt procedures W/O CC
193,MDC 07P,Biliary tract proc except only cholecyst W or W/O C.D.E. W CC
194,MDC 07P,Biliary tract proc except only cholecyst W or W/O C.D.E. W/O CC
195,MDC 07P,Cholecystectomy W C.D.E. W CC
196,MDC 07P,Cholecystectomy W C.D.E. W/O CC
197,MDC 07P,Cholecystectomy except by laparoscope W/O C.D.E. W CC
198,MDC 07P,Cholecystectomy except by laparoscope W/O C.D.E. W/O CC
199,MDC 07P,Hepatobiliary diagnostic procedure for malignancy
200,MDC 07P,Hepatobiliary diagnostic procedure for non-malignancy
201,MDC 07P,Other hepatobiliary or pancreas O.R. procedures
202,MDC 07M,Cirrhosis & alcoholic hepatitis
203,MDC 07M,Malignancy of hepatobiliary system or pancreas
204,MDC 07M,Disorders of pancreas except malignancy
205,MDC 07M,Disorders of liver except malig,cirr,alc hepa W CC
206,MDC 07M,Disorders of liver except malig,cirr,alc hepa W/O CC
207,MDC 07M,Disorders of the biliary tract W CC
208,MDC 07M,Disorders of the biliary tract W/O CC
209,MDC 08P,Major joint & limb reattachment procedures of lower extremity
210,MDC 08P,Hip & femur procedures except major joint age>17 W CC
211,MDC 08P,Hip & femur procedures except major joint age>17 W/O CC
212,MDC 08P,Hip & femur procedures except major joint age 0-17
213,MDC 08P,Amputation for musculoskeletal system & conn tissue disorders
216,MDC 08P,Biopsies of musculoskeletal system & connective tissue
217,MDC 08P,Wnd debrid & skn grft except hand,for muscskelet & conn tiss dis
218,MDC 08P,Lower extrem & humer proc except hip,foot,femur age>17 W CC
219,MDC 08P,Lower extrem & humer proc except hip,foot,femur age> 17 W/O CC
220,MDC 08P,Lower extrem & humer proc except hip,foot,femur age 0-17
223,MDC 08P,Major shoulder/elbow proc, or other upper extremity proc W CC
224,MDC 08P,Shoulder,elbow or forearm proc,exc major joint proc, W/O CC
225,MDC 08P,Foot procedures
226,MDC 08P,Soft tissue procedures W CC
227,MDC 08P,Soft tissue procedures W/O CC
228,MDC 08P,Major thumb or joint proc, or oth hand or wrist proc W CC
229,MDC 08P,Hand or wrist proc, except major joint proc, W/O CC
230,MDC 08P,Local excision & removal of int fix devices of hip & femur
231,MDC 08P,Local excision & removal of int fix devices except hip & femur
232,MDC 08P,Arthroscopy
233,MDC 08P,Other musculoskelet sys & conn tiss O.R. proc W CC
234,MDC 08P,Other musculoskelet sys & conn tiss O.R. proc W/O CC
235,MDC 08M,Fractures of femur
236,MDC 08M,Fractures of hip & pelvis
237,MDC 08M,Sprains,strains, & dislocations of hip, pelvis & thigh
238,MDC 08M,Osteomyelitis
239,MDC 08M,Pathological fractures & musculoskeletal & conn tiss malignancy
240,MDC 08M,Connective tissue disorders W CC
241,MDC 08M,Connective tissue disorders W/O CC
242,MDC 08M,Septic arthritis
243,MDC 08M,Medical back problems
244,MDC 08M,Bone diseases & specific arthropathies W CC
245,MDC 08M,Bone diseases & specific arthropathies W/O CC
246,MDC 08M,Non-specific arthropathies
247,MDC 08M,Signs & symptoms of musculoskeletal system & conn tissue
248,MDC 08M,Tendonitis, myositis & bursitis
249,MDC 08M,Aftercare, musculoskeletal system & connective tissue
250,MDC 08M,FX, SPRN, STRN & DISL of forearm, hand, foot age> 17 W CC
251,MDC 08M,FX, SPRN, STRN & DISL of forearm, hand, foot age> 17 W/O CC
252,MDC 08M,FX, SPRN, STRN & DISL of forearm, hand, foot age 0-17
253,MDC 08M,FX, SPRN, STRN & DISL of uparm,lowleg ex foot age> 17 W CC
254,MDC 08M,FX, SPRN, STRN & DISL of uparm,lowleg ex foot age> 17 W/O CC
255,MDC 08M,FX, SPRN, STRN & DISL of uparm,lowleg ex foot age 0-17
256,MDC 08M,Other musculoskeletal system & connective tissue diagnoses
257,MDC 09P,Total mastectomy for malignancy W CC
258,MDC 09P,Total mastectomy for malignancy W/O CC
259,MDC 09P,Subtotal mastectomy for malignancy W CC
260,MDC 09P,Subtotal mastectomy for malignancy W/O CC
261,MDC 09P,Breast proc for non-malignancy except biopsy & local excision
262,MDC 09P,Breast biopsy & local excision for non-malignancy
263,MDC 09P,Skin graft &/or debrid for SKN ulcer or cellulitis W CC
264,MDC 09P,Skin graft &/or debrid for SKN ulcer or cellulitis W/O CC
265,MDC 09P,Skin graft &/or debrid except for skin ulcer or cellulitis W CC
266,MDC 09P,Skin graft &/or debrid except for skin ulcer or cellulitis W/O CC
267,MDC 09P,Perianal & pilonidal procedures
268,MDC 09P,Skin, subcutaneous tissue & breast plastic procedures
269,MDC 09P,Other skin, subcut tiss & breast proc W CC
270,MDC 09P,Other skin, subcut tiss & breast proc W/O CC
271,MDC 09M,Skin ulcers
272,MDC 09M,Major skin disorders W CC
273,MDC 09M,Major skin disorders W/O CC
274,MDC 09M,Malignant breast disorders W CC
275,MDC 09M,Malignant breast disorders W/O CC
276,MDC 09M,Non-maligant breast disorders
277,MDC 09M,Cellulitis age> 17 W CC
278,MDC 09M,Cellulitis age> 17 W/O CC
279,MDC 09M,Cellulitis age 0-17
280,MDC 09M,Trauma to the skin, subcut tiss & breast age> 17 W CC
281,MDC 09M,Trauma to the skin, subcut tiss & breast age> 17 W/O CC
282,MDC 09M,Trauma to the skin, subcut tiss & breast age 0-17
283,MDC 09M,Minor skin disorders W CC
284,MDC 09M,Minor skin disorders W/O CC
285,MDC 10P,Amputat of lower limb for endocrine,nutrit,& metabol disorders
286,MDC 10P,Adrenal & pituitary procedures
287,MDC 10P,Skin grafts & wound debrid for endoc, nutrit & metab disorders
288,MDC 10P,O.R. Procedures for obesity
289,MDC 10P,Parathyroid procedures
290,MDC 10P,Thyroid procedures
291,MDC 10P,Thyroglossal procedures
292,MDC 10P,Other endocrine, nutrit & metab O.R. proc W CC
293,MDC 10P,Other endocrine, nutrit & metab O.R. proc W/O CC
294,MDC 10M,Diabetes age> 35
295,MDC 10M,Diabetes age 0-35
296,MDC 10M,Nutritional & misc metabolic disorders age> 17 W CC
297,MDC 10M,Nutritional & misc metabolic disorders age> 17 W/O CC
298,MDC 10M,Nutritional & misc metabolic disorders age 0-17
299,MDC 10M,Inborn errors of metabolism
300,MDC 10M,Endocrine disorders W CC
301,MDC 10M,Endocrine disorders W/O CC
302,MDC 11P,Kidney transplant
303,MDC 11P,Kidney,ureter & major bladder procedures for neoplasm
304,MDC 11P,Kidney,ureter & major bladder proc for non-neopl W CC
305,MDC 11P,Kidney,ureter & major bladder proc for non-neopl W/O CC
306,MDC 11P,Prostatectomy W CC
307,MDC 11P,Prostatectomy W/O CC
308,MDC 11P,Minor bladder procedures W CC
309,MDC 11P,Minor bladder procedures W/O CC
310,MDC 11P,Transurethral procedures W CC
311,MDC 11P,Transurethral procedures W/O CC
312,MDC 11P,Urethral procedures,age>17 W CC
313,MDC 11P,Urethral procedures,age>17 W/O CC
314,MDC 11P,Urethral procedures,age 0-17
315,MDC 11P,Other kidney & urinary tract O.R. procedures
316,MDC 11M,Renal failure
317,MDC 11M,Admit for renal dialysis
318,MDC 11M,Kidney & urinary tract neoplasms W CC
319,MDC 11M,Kidney & urinary tract neoplasms W/O CC
320,MDC 11M,Kidney & urinary tract infections age> 17 W CC
321,MDC 11M,Kidney & urinary tract infections age> 17 W/O CC
322,MDC 11M,Kidney & urinary tract infections age 0-17
323,MDC 11M,Urinary stones W CC, &/or ESW lithotripsy
324,MDC 11M,Urinary stones W/O CC
325,MDC 11M,Kidney & urinary tract signs & symptoms age> 17 W CC
326,MDC 11M,Kidney & urinary tract signs & symptons age> 17 W/O CC
327,MDC 11M,Kidney & urinary tract signs & symptons age 0-17
328,MDC 11M,Urethral stricture age>17 W CC
329,MDC 11M,Urethral stricture age>17 W/O CC
330,MDC 11M,Urethral stricture age 0-17
331,MDC 11M,Other kidney & urinary tract diagnoses age>17 W CC
332,MDC 11M,Other kidney & urinary tract diagnoses age>17 W/O CC
333,MDC 11M,Other kidney & urinary tract diagnoses age 0-17
334,MDC 12P,Major male pelvic procedures W CC
335,MDC 12P,Major male pelvic procedures W/O CC
336,MDC 12P,Transurethral prostatectomy W CC
337,MDC 12P,Transurethral prostatectomy W/O CC
338,MDC 12P,Testes procedures, for malignancy
339,MDC 12P,Testes procedures, non-malignancy age>17
340,MDC 12P,Testes procedures, non-malignancy age 0-17
341,MDC 12P,Penis procedures
342,MDC 12P,Circumcision age>17
343,MDC 12P,Circumcision age 0-17
344,MDC 12P,Other male reproductive system O.R. procedures for malignancy
345,MDC 12P,Other male reproductive system O.R. proc except for malignancy
346,MDC 12M,Malignancy, male reproductive system, W CC
347,MDC 12M,Malignancy, male reproductive system, W/O CC
348,MDC 12M,Benign prostatic hypertrophy W CC
349,MDC 12M,Benign prostatic hypertrophy W/O CC
350,MDC 12M,Inflammation of the male reproductive system
351,MDC 12M,Sterilization, male
352,MDC 12M,Other male reproductive system diagnoses
353,MDC 13P,PEL VIC evisceration, radical hysterectomy & radical vulvectomy
354,MDC 13P,Uterine,adnexa proc for non-ovarian/adnexal malig W CC
355,MDC 13P,Uterine,adnexa proc for non-ovarian/adnexal malig W/O CC
356,MDC 13P,Female reproductive system reconstructive procedures
357,MDC 13P,Uterine & adnexa proc for ovarian or adnexal malignancy
358,MDC 13P,Uterine & adnexa proc for non-malignancy W CC
359,MDC 13P,Uterine & adnexa proc for non-malignancy W/O CC
360,MDC 13P,Vagina, cervix & vulva procedures
361,MDC 13P,Laparoscopy & incisional tubal interruption
362,MDC 13P,Endoscopic tubal interruption
363,MDC 13P,D&C, Conization & radio-implant, for malignancy
364,MDC 13P,D&C, Conization except for malignancy
365,MDC 13P,Other female reproductive system O.R. procedures
366,MDC 13M,Malignancy, female reproductive system W CC
367,MDC 13M,Malignancy, female reproductive system W/O CC
368,MDC 13M,Infections, female reproductive system
369,MDC 13M,Menstrual & other female reproductive system disorders
370,MDC 14P,Cesarean section W CC
371,MDC 14P,Cesarean section W/O CC
372,MDC 14M,Vaginal delivery W complicating diagnoses
373,MDC 14M,Vaginal delivery W/O complicating diagnoses
374,MDC 14P,Vaginal delivery W sterilization &/OR D&C
375,MDC 14P,Vaginal delivery W O.R. proc except steril &/OR D&C
376,MDC 14M,Postpartum & post abortion diagnoses W/O O.R. procedure
377,MDC 14P,Postpartum & post abortion diagnoses W O.R. procedure
378,MDC 14M,Ectopic pregnancy
379,MDC 14M,Threatened abortion
380,MDC 14M,Abortion W/O D&C
381,MDC 14P,Abortion W D&C, aspiration curettage or hysterotomy
382,MDC 14M,False labor
383,MDC 14M,Other antepartum diagnoses W medical complications
384,MDC 14M,Other antepartum diagnoses W/O medical complications
385,MDC 15M,Neonates, died or transferred to another acute care facility
386,MDC 15M,Extreme immaturity or respiratory distress syndrome, neonate
387,MDC 15M,Prematurity W major problems
388,MDC 15M,Prematurity W/O major problems
389,MDC 15M,Full term neonate W major problems
390,MDC 15M,Neonate W other significant problems
391,MDC 15M,Normal newborn
392,MDC 16P,Splenectomy age>17
393,MDC 16P,Splenectomy age 0-17
394,MDC 16P,Other O.R. procedures of the blood and blood forming organs
395,MDC 16M,Red blood cell disorders age>17
396,MDC 16M,Red blood cell disorders age 0-17
397,MDC 16M,Coagulation disorders
398,MDC 16M,Reticuloendothelial & immunity disorders W CC
399,MDC 16M,Reticuloendothelial & immunity disorders W/O CC
400,MDC 17P,Lymphoma & leukemia W major O.R. procedure
401,MDC 17P,Lymphoma & non-acute leukemia W other O.R. proc W CC
402,MDC 17P,Lymphoma & non-acute leukemia W other O.R. proc W/O CC
403,MDC 17M,Lymphoma & non-acute leukemia W CC
404,MDC 17M,Lymphoma & non-acute leukemia W/O CC
405,MDC 17M,Acute leukemia W/O major O.R. procedure age 0-17
406,MDC 17P,Myeloprolif disord or poorly DIFF NEOPL W MAJ O.R.PROC W CC
407,MDC 17P,Myeloprolif disord or poorly diff neopl w maj o.r.proc w/o cc
408,MDC 17P,Myeloprolif disord or poorly diff neopl w other o.r.proc
409,MDC 17M,Radiotherapy
410,MDC 17M,Chemotherapy w/o acute leukemia as secondary diagnosis
411,MDC 17M,History of malignancy w/o endoscopy
412,MDC 17M,History of malignancy w endoscopy
413,MDC 17M,Other myeloprolif dis or poorly diff neopl diag W CC
414,MDC 17M,Other myeloprolif dis or poorly diff neopl diag W/O CC
415,MDC 18P,O.R. Procedure for infectious & parasitic diseases
416,MDC 18M,Septicemia age>17
417,MDC 18M,Septicemia age 0-17
418,MDC 18M,Postoperative & post-traumatic infections
419,MDC 18M,Fever of unknown origin age>17 W CC
420,MDC 18M,Fever of unknown origin age>17 W/O CC
421,MDC 18M,Viral illness age>17
422,MDC 18M,Viral illness & fever of unknown origin age 0-17
423,MDC 18M,Other infectious & parasitic diseases diagnoses
424,MDC 19P,O.R. Procedure W principal diagnoses of mental illness
425,MDC 19M,Acute adjust react & disturbances of psychosocial dysfunction
426,MDC 19M,Depressive neuroses
427,MDC 19M,Neuroses except depressive
428,MDC 19M,Disorders of personality & impulse control
429,MDC 19M,Organic disturbances & mental retardation
430,MDC 19M,Psychoses
431,MDC 19M,Childhood mental disorders
432,MDC 19M,Other mental disorder diagnoses
433,MDC 20M,Alcohol/drug abuse or dependence, left AMA
434,MDC 20M,Alc/drug abuse or depend, detox or oth sympt treat W CC
435,MDC 20M,Alc/drug abuse or depend, detox or oth sympt treat W/O CC
436,MDC 20M,ALC/Drug dependence w rehabilitation therapy
437,MDC 20M,ALC/Drug dependence, combined rehab & detox therapy
439,MDC 21P,Skin grafts for injuries
440,MDC 21P,Wound debridements for injuries
441,MDC 21P,Hand procedures for injuries
442,MDC 21P,Other O.R. procedures for injuries w cc
443,MDC 21P,Other O.R. procedures for injuries w/o cc
444,MDC 21M,Traumatic injury age>17 w cc
445,MDC 21M,Traumatic injury age>17 w/o cc
446,MDC 21M,Traumatic injury age 0-17
447,MDC 21M,Allergic reactions age>17
448,MDC 21M,Allergic reactions age 0-17
449,MDC 21M,Poisoning & toxic effects of drugs age>17 w cc
450,MDC 21M,Poisoning & toxic effects of drugs age>17 w/o cc
451,MDC 21M,Poisoning & toxic effects of drugs age 0-17
452,MDC 21M,Complications of treatment w cc
453,MDC 21M,Complications of treatment w/o cc
454,MDC 21M,Other injury, poisoning & toxic effect diag w cc
455,MDC 21M,Other injury, poisoning & toxic effect diag w/o cc
456,MDC 22M,Burns, transferred to another acute care facility
457,MDC 22M,Extensive burns w/o O.R. procedure
458,MDC 22P,Non-extensive burns w skin graft
459,MDC 22P,Non-extensive burns w wound debridement or other O.R. proc
460,MDC 22M,Non-extensive burns w/o O.R. procedure
461,MDC 23P,O.R. proc w Diagnoses of other contact w health services
462,MDC 23M,Rehabilitation
463,MDC 23M,Signs & symptoms w cc
464,MDC 23M,Signs & symptoms w/o cc
465,MDC 23M,Aftercare w history of malignancy as secondary diagnosis
466,MDC 23M,Aftercare w/o history of malignancy as secondary diagnosis
467,MDC 23M,Other factors influencing health status
468, P,Extensive O.R. procedure unrelated to principal diagnosis
469, Principal diagnosis invalid as discharge diagnosis
470, Ungroupable
471,MDC 08P,Bilateral or multiple major joint procs of lower extremity
472,MDC 22P,Extensive burns w O.R. procedure
473,MDC 17M,Acute leukemia w/o major O.R. procedure age>17
475,MDC 04M,Respiratory system diagnosis with ventilator support
476, P,Prostatic O.R. procedure unrelated to principal diagnosis
477, P,Non-extensive O.R. procedure unrelated to principal diagnosis
478,MDC 05P,Other vascular procedures w cc
479,MDC 05P,Other vascular procedures w/o cc
480, P,Liver transplant
481, P,Bone marrow transplant
482,P,Tracheostomy for face,mouth & neck diagnoses
483,P,Tracheostomy except for face,mouth & neck diagnoses
484,MDC 24P,Craniotomy for multiple significant trauma
485,MDC 24P,Limb reattachment, hip and femur proc for multiple significant trauma
486,MDC 24P,Other O.R. procedures for multiple significant trauma
487,MDC 24M,Other multiple significant trauma
488,MDC 25P,HIV w Extensive O.R. procedure
489,MDC 25M,HIV w Major related condition
490,MDC 25M,HIV w or w/o Other related condition
491,MDC 08P,Major joint & limb reattachment procedures of upper extremity
492,MDC 17M,Chemotherapy w acute leukemia as secondary diagnosis
493,MDC 07P,Laparoscopic cholecystectomy w/o C.D.E. w cc
494,MDC 07P,Laparoscopic cholecystectomy w/o C.D.E. w/o cc
495,P,Lung transplant
496,MDC 08P,Combined anterior/posterior spinal fusion
497,MDC 08P,Spinal fusion w cc
498,MDC 08P,Spinal fusion w/o cc
499,MDC 08P,Back & neck procedures except spinal fusion w cc
500,MDC 08P,Back & neck procedures except spinal fusion w/o cc
501,MDC 08P,Knee procedures w PDX of infection w cc
502,MDC 08P,Knee procedures w PDX of infection w/o cc
503,MDC 08P,Knee procedures w/o PDX of infection
892, MDC 15,Extreme immaturity or respiratory distress syndrome, neonate, with ICD-9-CM code 765.0
893, MDC 15, Extreme immaturity or respiratory distress syndrome, neonate, without ICD-9-CM code 765.0, in a level I or II nursery
894, MDC 15, Extreme immaturity or respiratory distress syndrome, neonate, without ICD-9-CM code 765.0, in a level III nursery
895, MDC 15, Prematurity with major problems, with birthweight <<or=1750 grams, in level I or II nursery
896, MDC 15, Prematurity with major problems, with birthweight <<or=1750 grams, in level III nursery
897, MDC, 15, Prematurity with major problems, with birthweight > 1750 grams, in level I or II nursery
898, MDC 15, Prematurity with major problems, with birthweight > 1750 grams, in level III nursery
HISTORY: Eff 10-1-84; 7-1-85; 7-3-86; 10-19-87; 6-30-89 (Emer.); 7-21-89; 7-1-90; 9-3-91 (Emer.); 11-10-91; 7-1-92; 1-20-95; 2-1-00; 8-1-02
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01, 5111.02
R.C. 119.032 review dates: 5/9/2002 and 08/01/2007