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  • 1. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC002 No No PRE SURG Heart transplant or implant of heart assist 16.2735 " $145,208.82 " system w/o MCC003 Yes No PRE SURG "ECMO or trach w MV 96+ hrs or PDX exc face, 18.7707 " $167,490.66 " mouth & neck w maj O.R."004 Yes No PRE SURG "Trach w MV 96+ hrs or PDX exc face, mouth & 11.4219 " $101,917.43 " neck w/o maj O.R."005 No No PRE SURG Liver transplant w MCC or intestinal transplant 10.6120 " $94,690.77 "006 No No PRE SURG Liver transplant w/o MCC 7.2562 " $64,746.65 "007 No No PRE SURG Lung transplant 8.4002 " $74,955.00 "008 No No PRE SURG Simultaneous pancreas/kidney transplant 5.1726 " $46,154.91 "009 No No PRE SURG Bone marrow transplant 6.4842 " $57,858.62 "010 No No PRE SURG Pancreas transplant 3.8902 " $34,712.10 "011 No No PRE SURG "Tracheostomy for face,mouth & neck 4.1482 " $37,014.48 " diagnoses w MCC"012 No No PRE SURG "Tracheostomy for face,mouth & neck 3.2472 " $28,975.19 " diagnoses w CC"013 No No PRE SURG "Tracheostomy for face,mouth & neck 2.6760 " $23,878.23 " diagnoses w/o CC/MCC"020 No No 01 SURG Intracranial vascular procedures w PDX 7.7073 " $68,772.03 " hemorrhage w MCC021 No No 01 SURG Intracranial vascular procedures w PDX 6.7021 " $59,802.83 " hemorrhage w CC022 No No 01 SURG Intracranial vascular procedures w PDX 5.6085 " $50,044.89 " hemorrhage w/o CC/MCC023 No No 01 SURG Cranio w major dev impl/acute complex CNS 4.7036 " $41,970.40 " PDX w MCC or chemo implant024 No No 01 SURG Cranio w major dev impl/acute complex CNS 3.8978 " $34,780.00 " PDX w/o MCC025 Yes No 01 SURG Craniotomy & endovascular intracranial 4.2362 " $37,799.63 " procedures w MCC026 Yes No 01 SURG Craniotomy & endovascular intracranial 3.1582 " $28,180.33 " procedures w CC027 Yes No 01 SURG Craniotomy & endovascular intracranial 2.3259 " $20,753.82 " procedures w/o CC/MCC028 Yes Yes 01 SURG Spinal procedures w MCC 4.2339 " $37,778.71 " -1-
  • 2. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC029 Yes Yes 01 SURG Spinal procedures w CC or spinal 2.8356 " $25,302.04 " neurostimulators030 Yes Yes 01 SURG Spinal procedures w/o CC/MCC 1.7617 " $15,719.38 "031 Yes No 01 SURG Ventricular shunt procedures w MCC 3.2226 " $28,754.91 "032 Yes No 01 SURG Ventricular shunt procedures w CC 1.9342 " $17,259.28 "033 Yes No 01 SURG Ventricular shunt procedures w/o CC/MCC 1.4281 " $12,742.99 "034 No No 01 SURG Carotid artery stent procedure w MCC 2.5438 " $22,698.11 "035 No No 01 SURG Carotid artery stent procedure w CC 1.8996 " $16,949.90 "036 No No 01 SURG Carotid artery stent procedure w/o CC/MCC 1.6977 " $15,148.74 "037 No No 01 SURG Extracranial procedures w MCC 2.2630 " $20,192.60 "038 No No 01 SURG Extracranial procedures w CC 1.4686 " $13,104.54 "039 No No 01 SURG Extracranial procedures w/o CC/MCC 1.0909 " $9,734.21 "040 Yes Yes 01 SURG Periph/cranial nerve & other nerv syst proc w 3.2550 " $29,044.05 " MCC041 Yes Yes 01 SURG Periph/cranial nerve & other nerv syst proc w 2.3595 " $21,053.82 " CC or periph neurostim042 Yes Yes 01 SURG Periph/cranial nerve & other nerv syst proc w/o 1.8710 " $16,694.72 " CC/MCC052 No No 01 MED Spinal disorders & injuries w CC/MCC 1.4329 " $12,785.67 "053 No No 01 MED Spinal disorders & injuries w/o CC/MCC 1.1172 " $9,968.65 "054 Yes No 01 MED Nervous system neoplasms w MCC 1.4228 " $12,695.47 "055 Yes No 01 MED Nervous system neoplasms w/o MCC 1.1213 " $10,005.26 "056 Yes No 01 MED Degenerative nervous system disorders w MCC 1.2820 " $11,439.73 "057 Yes No 01 MED Degenerative nervous system disorders w/o 0.8951 " $7,987.21 " MCC058 No No 01 MED Multiple sclerosis & cerebellar ataxia w MCC 1.2669 " $11,304.92 "059 No No 01 MED Multiple sclerosis & cerebellar ataxia w CC 0.9226 " $8,232.01 "060 No No 01 MED Multiple sclerosis & cerebellar ataxia w/o 0.8160 " $7,281.59 " CC/MCC061 No No 01 MED Acute ischemic stroke w use of thrombolytic 2.5541 " $22,790.15 " agent w MCC062 No No 01 MED Acute ischemic stroke w use of thrombolytic 2.0886 " $18,636.26 " agent w CC063 No No 01 MED Acute ischemic stroke w use of thrombolytic 1.8642 " $16,634.11 " agent w/o CC/MCC -2-
  • 3. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC064 Yes No 01 MED Intracranial hemorrhage or cerebral infarction w 1.5470 " $13,804.04 " MCC065 Yes No 01 MED Intracranial hemorrhage or cerebral infarction w 1.1901 " $10,618.98 " CC066 Yes No 01 MED Intracranial hemorrhage or cerebral infarction w/ 1.0303 " $9,193.16 " o CC/MCC067 No No 01 MED Nonspecific cva & precerebral occlusion w/o 1.2194 " $10,880.40 " infarct w MCC068 No No 01 MED Nonspecific cva & precerebral occlusion w/o 0.9131 " $8,147.26 " infarct w/o MCC069 No No 01 MED Transient ischemia 0.7339 " $6,548.96 "070 Yes No 01 MED Nonspecific cerebrovascular disorders w MCC 1.6212 " $14,465.88 "071 Yes No 01 MED Nonspecific cerebrovascular disorders w CC 1.2522 " $11,173.62 "072 Yes No 01 MED Nonspecific cerebrovascular disorders w/o CC/ 0.9586 " $8,553.80 " MCC073 No No 01 MED Cranial & peripheral nerve disorders w MCC 1.1717 " $10,455.12 "074 No No 01 MED Cranial & peripheral nerve disorders w/o MCC 0.8954 " $7,990.05 "075 No No 01 MED Viral meningitis w CC/MCC 1.5369 " $13,713.60 "076 No No 01 MED Viral meningitis w/o CC/MCC 1.1439 " $10,207.04 "077 No No 01 MED Hypertensive encephalopathy w MCC 1.4611 " $13,037.54 "078 No No 01 MED Hypertensive encephalopathy w CC 1.0996 " $9,811.81 "079 No No 01 MED Hypertensive encephalopathy w/o CC/MCC 0.9839 " $8,779.45 "080 No No 01 MED Nontraumatic stupor & coma w MCC 0.9014 " $8,043.41 "081 No No 01 MED Nontraumatic stupor & coma w/o MCC 0.7161 " $6,389.35 "082 No No 01 MED "Traumatic stupor & coma, coma >1 hr w MCC" 1.6724 " $14,922.89 "083 No No 01 MED "Traumatic stupor & coma, coma >1 hr w CC" 1.3328 " $11,892.63 "084 No No 01 MED "Traumatic stupor & coma, coma >1 hr w/o CC/ 1.1106 " $9,909.67 " MCC"085 Yes No 01 MED "Traumatic stupor & coma, coma <1 hr w MCC" 1.6946 " $15,120.82 "086 Yes No 01 MED "Traumatic stupor & coma, coma <1 hr w CC" 1.2337 " $11,008.40 "087 Yes No 01 MED "Traumatic stupor & coma, coma <1 hr w/o CC/ 0.9235 " $8,239.95 " MCC"088 No No 01 MED Concussion w MCC 1.2968 " $11,571.37 "089 No No 01 MED Concussion w CC 0.9479 " $8,458.19 "090 No No 01 MED Concussion w/o CC/MCC 0.7405 " $6,607.40 "091 Yes No 01 MED Other disorders of nervous system w MCC 1.3242 " $11,816.13 " -3-
  • 4. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC092 Yes No 01 MED Other disorders of nervous system w CC 0.9529 " $8,502.44 "093 Yes No 01 MED Other disorders of nervous system w/o CC/MCC 0.7710 " $6,879.51 "094 No No 01 MED Bacterial & tuberculous infections of nervous 3.1499 " $28,106.48 " system w MCC095 No No 01 MED Bacterial & tuberculous infections of nervous 2.5679 " $22,913.41 " system w CC096 No No 01 MED Bacterial & tuberculous infections of nervous 2.3482 " $20,952.79 " system w/o CC/MCC097 No No 01 MED Non-bacterial infect of nervous sys exc viral 2.6665 " $23,792.80 " meningitis w MCC098 No No 01 MED Non-bacterial infect of nervous sys exc viral 2.0568 " $18,353.21 " meningitis w CC099 No No 01 MED Non-bacterial infect of nervous sys exc viral 1.8177 " $16,218.91 " meningitis w/o CC/MCC100 Yes No 01 MED Seizures w MCC 1.2500 " $11,153.78 "101 Yes No 01 MED Seizures w/o MCC 0.8258 " $7,368.71 "102 No No 01 MED Headaches w MCC 0.8710 " $7,771.58 "103 No No 01 MED Headaches w/o MCC 0.6677 " $5,957.78 "113 No No 02 SURG Orbital procedures w CC/MCC 1.4141 " $12,617.90 "114 No No 02 SURG Orbital procedures w/o CC/MCC 1.0292 " $9,183.15 "115 No No 02 SURG Extraocular procedures except orbit 1.1185 " $9,980.14 "116 No No 02 SURG Intraocular procedures w CC/MCC 0.8891 " $7,933.87 "117 No No 02 SURG Intraocular procedures w/o CC/MCC 0.7094 " $6,329.95 "121 No No 02 MED Acute major eye infections w CC/MCC 0.8800 " $7,852.61 "122 No No 02 MED Acute major eye infections w/o CC/MCC 0.6608 " $5,896.29 "123 No No 02 MED Neurological eye disorders 0.7224 " $6,446.31 "124 No No 02 MED Other disorders of the eye w MCC 0.9308 " $8,305.77 "125 No No 02 MED Other disorders of the eye w/o MCC 0.6792 " $6,060.65 "129 No No 03 SURG Major head & neck procedures w CC/MCC or 1.7992 " $16,053.95 " major device130 No No 03 SURG Major head & neck procedures w/o CC/MCC 1.3987 " $12,480.53 "131 No No 03 SURG Cranial/facial procedures w CC/MCC 1.6300 " $14,544.40 "132 No No 03 SURG Cranial/facial procedures w/o CC/MCC 1.2054 " $10,755.80 "133 No No 03 SURG "Other ear, nose, mouth & throat O.R. 1.4331 " $12,787.74 " procedures w CC/MCC" -4-
  • 5. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC134 No No 03 SURG "Other ear, nose, mouth & throat O.R. 0.9474 " $8,453.26 " procedures w/o CC/MCC"135 No No 03 SURG Sinus & mastoid procedures w CC/MCC 1.5318 " $13,668.56 "136 No No 03 SURG Sinus & mastoid procedures w/o CC/MCC 1.1094 " $9,899.04 "137 No No 03 SURG Mouth procedures w CC/MCC 1.2677 " $11,311.40 "138 No No 03 SURG Mouth procedures w/o CC/MCC 0.8474 " $7,560.95 "139 No No 03 SURG Salivary gland procedures 0.8470 " $7,557.58 "146 No No 03 MED "Ear, nose, mouth & throat malignancy w MCC" 1.7734 " $15,824.42 "147 No No 03 MED "Ear, nose, mouth & throat malignancy w CC" 1.2182 " $10,869.79 "148 No No 03 MED "Ear, nose, mouth & throat malignancy w/o CC/ 1.0070 " $8,985.84 " MCC"149 No No 03 MED Dysequilibrium 0.6154 " $5,490.79 "150 No No 03 MED Epistaxis w MCC 0.9916 " $8,848.02 "151 No No 03 MED Epistaxis w/o MCC 0.6227 " $5,556.22 "152 No No 03 MED Otitis media & URI w MCC 0.8160 " $7,281.35 "153 No No 03 MED Otitis media & URI w/o MCC 0.6207 " $5,538.70 "154 No No 03 MED Nasal trauma & deformity w MCC 1.1294 " $10,077.30 "155 No No 03 MED Nasal trauma & deformity w CC 0.8630 " $7,700.25 "156 No No 03 MED Nasal trauma & deformity w/o CC/MCC 0.7412 " $6,613.62 "157 No No 03 MED Dental & Oral Diseases w MCC 1.1909 " $10,626.71 "158 No No 03 MED Dental & Oral Diseases w CC 0.8653 " $7,721.10 "159 No No 03 MED Dental & Oral Diseases w/o CC/MCC 0.7361 " $6,567.98 "163 Yes No 04 SURG Major chest procedures w MCC 4.0452 " $36,095.61 "164 Yes No 04 SURG Major chest procedures w CC 2.8081 " $25,056.43 "165 Yes No 04 SURG Major chest procedures w/o CC/MCC 2.4106 " $21,510.01 "166 Yes No 04 SURG Other resp system O.R. procedures w MCC 3.2677 " $29,157.45 "167 Yes No 04 SURG Other resp system O.R. procedures w CC 2.4151 " $21,549.91 "168 Yes No 04 SURG Other resp system O.R. procedures w/o 1.8181 " $16,222.67 " CC/MCC175 Yes No 04 MED Pulmonary embolism w MCC 1.4152 " $12,627.60 "176 Yes No 04 MED Pulmonary embolism w/o MCC 1.1580 " $10,332.77 "177 Yes No 04 MED Respiratory infections & inflammations w MCC 1.8444 " $16,457.48 "178 Yes No 04 MED Respiratory infections & inflammations w CC 1.5636 " $13,951.87 "179 Yes No 04 MED Respiratory infections & inflammations w/o CC/ 1.2754 " $11,380.07 " MCC180 No No 04 MED Respiratory neoplasms w MCC 1.5550 " $13,875.12 " -5-
  • 6. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC181 No No 04 MED Respiratory neoplasms w CC 1.3126 " $11,712.68 "182 No No 04 MED Respiratory neoplasms w/o CC/MCC 1.1455 " $10,221.32 "183 No No 04 MED Major chest trauma w MCC 1.2664 " $11,300.27 "184 No No 04 MED Major chest trauma w CC 0.9611 " $8,576.22 "185 No No 04 MED Major chest trauma w/o CC/MCC 0.7298 " $6,512.23 "186 Yes No 04 MED Pleural effusion w MCC 1.4542 " $12,975.43 "187 Yes No 04 MED Pleural effusion w CC 1.1947 " $10,660.22 "188 Yes No 04 MED Pleural effusion w/o CC/MCC 0.9745 " $8,695.71 "189 No No 04 MED Pulmonary edema & respiratory failure 1.3660 " $12,189.26 "190 Yes No 04 MED Chronic obstructive pulmonary disease w MCC 1.1138 " $9,938.84 "191 Yes No 04 MED Chronic obstructive pulmonary disease w CC 0.9405 " $8,392.26 "192 Yes No 04 MED Chronic obstructive pulmonary disease w/o CC/ 0.8145 " $7,267.62 " MCC193 Yes No 04 MED Simple pneumonia & pleurisy w MCC 1.2505 " $11,158.32 "194 Yes No 04 MED Simple pneumonia & pleurisy w CC 1.0235 " $9,132.26 "195 Yes No 04 MED Simple pneumonia & pleurisy w/o CC/MCC 0.8398 " $7,493.23 "196 Yes No 04 MED Interstitial lung disease w MCC 1.3781 " $12,297.16 "197 Yes No 04 MED Interstitial lung disease w CC 1.1458 " $10,224.09 "198 Yes No 04 MED Interstitial lung disease w/o CC/MCC 0.9654 " $8,614.20 "199 No No 04 MED Pneumothorax w MCC 1.4699 " $13,115.99 "200 No No 04 MED Pneumothorax w CC 1.0753 " $9,595.31 "201 No No 04 MED Pneumothorax w/o CC/MCC 0.8588 " $7,662.73 "202 No No 04 MED Bronchitis & asthma w CC/MCC 0.7841 " $6,996.65 "203 No No 04 MED Bronchitis & asthma w/o CC/MCC 0.6252 " $5,578.34 "204 No No 04 MED Respiratory signs & symptoms 0.6658 " $5,941.00 "205 Yes No 04 MED Other respiratory system diagnoses w MCC 1.0636 " $9,490.62 "206 Yes No 04 MED Other respiratory system diagnoses w/o MCC 0.7848 " $7,002.35 "207 Yes No 04 MED Respiratory system diagnosis w ventilator 5.1231 " $45,713.39 " support 96+ hours208 No No 04 MED Respiratory system diagnosis w ventilator 2.2463 " $20,043.81 " support <96 hours215 No No 05 SURG Other heart assist system implant 12.0016 " $107,090.71 "216 Yes No 05 SURG Cardiac valve & oth maj cardiothoracic proc w 9.3040 " $83,019.88 " card cath w MCC217 Yes No 05 SURG Cardiac valve & oth maj cardiothoracic proc w 7.5813 " $67,647.80 " card cath w CC -6-
  • 7. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC218 Yes No 05 SURG Cardiac valve & oth maj cardiothoracic proc w 6.8595 " $61,207.54 " card cath w/o CC/MCC219 Yes Yes 05 SURG Cardiac valve & oth maj cardiothoracic proc w/o 7.2072 " $64,310.13 " card cath w MCC220 Yes Yes 05 SURG Cardiac valve & oth maj cardiothoracic proc w/o 5.7278 " $51,109.04 " card cath w CC221 Yes Yes 05 SURG Cardiac valve & oth maj cardiothoracic proc w/o 5.2463 " $46,813.03 " card cath w/o CC/MCC222 No No 05 SURG Cardiac defib implant w cardiac cath w AMI/HF/ 8.0234 " $71,592.36 " shock w MCC223 No No 05 SURG Cardiac defib implant w cardiac cath w AMI/HF/ 6.8809 " $61,398.07 " shock w/o MCC224 No No 05 SURG Cardiac defib implant w cardiac cath w/o 7.3178 " $65,296.69 " AMI/HF/shock w MCC225 No No 05 SURG Cardiac defib implant w cardiac cath w/o 6.2956 " $56,175.53 " AMI/HF/shock w/o MCC226 No No 05 SURG Cardiac defibrillator implant w/o cardiac cath w 5.9123 " $52,755.81 " MCC227 No No 05 SURG Cardiac defibrillator implant w/o cardiac cath w/o 5.0411 " $44,982.09 " MCC228 Yes No 05 SURG Other cardiothoracic procedures w MCC 6.7400 " $60,140.69 "229 Yes No 05 SURG Other cardiothoracic procedures w CC 5.3191 " $47,461.99 "230 Yes No 05 SURG Other cardiothoracic procedures w/o CC/MCC 4.7847 " $42,693.80 "231 No No 05 SURG Coronary bypass w PTCA w MCC 7.2993 " $65,132.06 "232 No No 05 SURG Coronary bypass w PTCA w/o MCC 6.1947 " $55,275.58 "233 Yes No 05 SURG Coronary bypass w cardiac cath w MCC 6.4496 " $57,549.60 "234 Yes No 05 SURG Coronary bypass w cardiac cath w/o MCC 4.9216 " $43,915.25 "235 Yes No 05 SURG Coronary bypass w/o cardiac cath w MCC 5.1381 " $45,846.83 "236 Yes No 05 SURG Coronary bypass w/o cardiac cath w/o MCC 3.7307 " $33,288.83 "237 No No 05 SURG Major cardiovasc procedures w MCC or thoracic 4.4954 " $40,112.61 " aortic anuerysm repair238 No No 05 SURG Major cardiovasc procedures w/o MCC 3.1891 " $28,456.48 "239 Yes No 05 SURG Amputation for circ sys disorders exc upper limb 3.9454 " $35,204.70 " & toe w MCC240 Yes No 05 SURG Amputation for circ sys disorders exc upper limb 2.9983 " $26,753.83 " & toe w CC -7-
  • 8. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC241 Yes No 05 SURG Amputation for circ sys disorders exc upper limb 2.4709 " $22,048.05 " & toe w/o CC/MCC242 Yes No 05 SURG Permanent cardiac pacemaker implant w MCC 3.2586 " $29,076.66 "243 Yes No 05 SURG Permanent cardiac pacemaker implant w CC 2.5483 " $22,738.49 "244 Yes No 05 SURG Permanent cardiac pacemaker implant w/o CC/ 2.1367 " $19,065.66 " MCC245 No No 05 SURG AICD lead & generator procedures 3.1073 " $27,726.81 "246 No No 05 SURG Perc cardiovasc proc w drug-eluting stent w 2.9046 " $25,917.65 " MCC or 4+ vessels/stents247 No No 05 SURG Perc cardiovasc proc w drug-eluting stent w/o 2.1255 " $18,965.58 " MCC248 No No 05 SURG Perc cardiovasc proc w non-drug-eluting stent w 2.5180 " $22,468.08 " MCC or 4+ ves/stents249 No No 05 SURG Perc cardiovasc proc w non-drug-eluting stent 1.8124 " $16,172.24 " w/o MCC250 No No 05 SURG Perc cardiovasc proc w/o coronary artery stent 2.4870 " $22,191.31 " or AMI w MCC251 No No 05 SURG Perc cardiovasc proc w/o coronary artery stent 1.7480 " $15,597.32 " or AMI w/o MCC252 No No 05 SURG Other vascular procedures w MCC 2.7564 " $24,594.95 "253 No No 05 SURG Other vascular procedures w CC 2.2536 " $20,108.45 "254 No No 05 SURG Other vascular procedures w/o CC/MCC 1.6786 " $14,978.05 "255 Yes No 05 SURG Upper limb & toe amputation for circ system 2.1486 " $19,172.12 " disorders w MCC256 Yes No 05 SURG Upper limb & toe amputation for circ system 1.6847 " $15,032.62 " disorders w CC257 Yes No 05 SURG Upper limb & toe amputation for circ system 1.3990 " $12,483.65 " disorders w/o CC/MCC258 No No 05 SURG Cardiac pacemaker device replacement w MCC 2.2926 " $20,457.20 "259 No No 05 SURG Cardiac pacemaker device replacement w/o 1.6553 " $14,769.88 " MCC260 No No 05 SURG Cardiac pacemaker revision except device 2.1625 " $19,296.00 " replacement w MCC261 No No 05 SURG Cardiac pacemaker revision except device 1.3212 " $11,788.90 " replacement w CC -8-
  • 9. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC262 No No 05 SURG Cardiac pacemaker revision except device 1.1245 " $10,034.34 " replacement w/o CC/MCC263 No No 05 SURG Vein ligation & stripping 1.4977 " $13,363.74 "264 Yes No 05 SURG Other circulatory system O.R. procedures 2.4840 " $22,164.32 "280 Yes No 05 MED "Acute myocardial infarction, discharged alive w 1.7391 " $15,518.31 " MCC"281 Yes No 05 MED "Acute myocardial infarction, discharged alive w 1.3126 " $11,712.22 " CC"282 Yes No 05 MED "Acute myocardia infarction, discharged alive w/ 1.0617 " $9,473.98 " o CC/MCC"283 No No 05 MED "Acute myocardial infarction, expired w MCC" 1.5787 " $14,086.30 "284 No No 05 MED "Acute myocardial infarction, expired w CC" 1.2074 " $10,773.61 "285 No No 05 MED "Acute myocardial infarction, expired w/o 1.0421 " $9,298.23 " CC/MCC"286 No No 05 MED "Circulatory disorders except AMI, w card cath w 1.6667 " $14,871.57 " MCC"287 No No 05 MED "Circulatory disorders except AMI, w card cath 1.1412 " $10,183.08 " w/o MCC"288 Yes No 05 MED Acute & subacute endocarditis w MCC 2.9143 " $26,004.67 "289 Yes No 05 MED Acute & subacute endocarditis w CC 2.3075 " $20,590.12 "290 Yes No 05 MED Acute & subacute endocarditis w/o CC/MCC 1.9733 " $17,607.91 "291 Yes No 05 MED Heart failure & shock w MCC 1.2585 " $11,229.61 "292 Yes No 05 MED Heart failure & shock w CC 1.0134 " $9,042.36 "293 Yes No 05 MED Heart failure & shock w/o CC/MCC 0.8765 " $7,820.80 "294 No No 05 MED Deep vein thrombophlebitis w CC/MCC 0.8665 " $7,731.44 "295 No No 05 MED Deep vein thrombophlebitis w/o CC/MCC 0.6950 " $6,201.19 "296 No No 05 MED "Cardiac arrest, unexplained w MCC" 1.1144 " $9,944.18 "297 No No 05 MED "Cardiac arrest, unexplained w CC" 0.8490 " $7,575.28 "298 No No 05 MED "Cardiac arrest, unexplained w/o CC/MCC" 0.7207 " $6,431.14 "299 Yes No 05 MED Peripheral vascular disorders w MCC 1.2220 " $10,903.56 "300 Yes No 05 MED Peripheral vascular disorders w CC 0.9451 " $8,433.25 "301 Yes No 05 MED Peripheral vascular disorders w/o CC/MCC 0.7183 " $6,409.40 "302 No No 05 MED Atherosclerosis w MCC 0.8236 " $7,349.03 "303 No No 05 MED Atherosclerosis w/o MCC 0.6055 " $5,403.08 "304 No No 05 MED Hypertension w MCC 0.8312 " $7,416.70 "305 No No 05 MED Hypertension w/o MCC 0.5942 " $5,302.45 " -9-
  • 10. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC306 No No 05 MED Cardiac congenital & valvular disorders w MCC 1.2007 " $10,714.22 "307 No No 05 MED Cardiac congenital & valvular disorders w/o 0.8224 " $7,338.29 " MCC308 No No 05 MED Cardiac arrhythmia & conduction disorders w 1.0841 " $9,673.65 " MCC309 No No 05 MED Cardiac arrhythmia & conduction disorders w 0.8233 " $7,346.48 " CC310 No No 05 MED Cardiac arrhythmia & conduction disorders w/o 0.6439 " $5,745.32 " CC/MCC311 No No 05 MED Angina pectoris 0.5118 " $4,567.05 "312 No No 05 MED Syncope & collapse 0.7197 " $6,422.02 "313 No No 05 MED Chest pain 0.5489 " $4,897.65 "314 Yes No 05 MED Other circulatory system diagnoses w MCC 1.5606 " $13,925.00 "315 Yes No 05 MED Other circulatory system diagnoses w CC 1.1720 " $10,457.65 "316 Yes No 05 MED Other circulatory system diagnoses w/o 0.9075 " $8,097.46 " CC/MCC326 Yes No 06 SURG "Stomach, esophageal & duodenal proc w 5.1660 " $46,096.01 " MCC"327 Yes No 06 SURG "Stomach, esophageal & duodenal proc w CC" 3.2941 " $29,392.84 "328 Yes No 06 SURG "Stomach, esophageal & duodenal proc w/o CC/ 1.8017 " $16,076.44 " MCC"329 Yes No 06 SURG Major small & large bowel procedures w MCC 4.5059 " $40,205.85 "330 Yes No 06 SURG Major small & large bowel procedures w CC 2.8935 " $25,818.85 "331 Yes No 06 SURG Major small & large bowel procedures w/o 1.8415 " $16,432.08 " CC/MCC332 Yes No 06 SURG Rectal resection w MCC 3.7139 " $33,138.81 "333 Yes No 06 SURG Rectal resection w CC 2.5787 " $23,010.15 "334 Yes No 06 SURG Rectal resection w/o CC/MCC 1.7856 " $15,933.25 "335 Yes No 06 SURG Peritoneal adhesiolysis w MCC 3.4785 " $31,038.31 "336 Yes No 06 SURG Peritoneal adhesiolysis w CC 2.4776 " $22,107.80 "337 Yes No 06 SURG Peritoneal adhesiolysis w/o CC/MCC 1.6984 " $15,154.91 "338 No No 06 SURG Appendectomy w complicated principal diag w 2.7254 " $24,318.31 " MCC339 No No 06 SURG Appendectomy w complicated principal diag w 1.9805 " $17,671.81 " CC -10-
  • 11. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC340 No No 06 SURG Appendectomy w complicated principal diag w/o 1.3849 " $12,357.77 " CC/MCC341 No No 06 SURG Appendectomy w/o complicated principal diag w 1.8824 " $16,796.24 " MCC342 No No 06 SURG Appendectomy w/o complicated principal diag w 1.3562 " $12,101.75 " CC343 No No 06 SURG Appendectomy w/o complicated principal diag 0.9887 " $8,822.06 " w/o CC/MCC344 No No 06 SURG Minor small & large bowel procedures w MCC 2.5156 " $22,446.96 "345 No No 06 SURG Minor small & large bowel procedures w CC 1.7028 " $15,194.15 "346 No No 06 SURG Minor small & large bowel procedures w/o 1.2617 " $11,258.20 " CC/MCC347 No No 06 SURG Anal & stomal procedures w MCC 1.7658 " $15,756.66 "348 No No 06 SURG Anal & stomal procedures w CC 1.2781 " $11,404.62 "349 No No 06 SURG Anal & stomal procedures w/o CC/MCC 0.8629 " $7,699.49 "350 No No 06 SURG Inguinal & femoral hernia procedures w MCC 1.8330 " $16,355.74 "351 No No 06 SURG Inguinal & femoral hernia procedures w CC 1.2449 " $11,108.16 "352 No No 06 SURG Inguinal & femoral hernia procedures w/o 0.8967 " $8,001.41 " CC/MCC353 No No 06 SURG Hernia procedures except inguinal & femoral w 2.0241 " $18,060.98 " MCC354 No No 06 SURG Hernia procedures except inguinal & femoral w 1.4092 " $12,574.70 " CC355 No No 06 SURG Hernia procedures except inguinal & femoral w/ 1.0147 " $9,054.53 " o CC/MCC356 Yes No 06 SURG Other digestive system O.R. procedures w MCC 3.3790 " $30,150.83 "357 Yes No 06 SURG Other digestive system O.R. procedures w CC 2.4946 " $22,259.67 "358 Yes No 06 SURG Other digestive system O.R. procedures w/o 1.7333 " $15,466.38 " CC/MCC368 No No 06 MED Major esophageal disorders w MCC 1.3788 " $12,303.13 "369 No No 06 MED Major esophageal disorders w CC 1.0839 " $9,671.68 "370 No No 06 MED Major esophageal disorders w/o CC/MCC 0.9558 " $8,528.33 "371 Yes No 06 MED Major gastrointestinal disorders & peritoneal 1.6263 " $14,511.73 " infections w MCC372 Yes No 06 MED Major gastrointestinal disorders & peritoneal 1.3059 " $11,652.53 " infections w CC -11-
  • 12. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC373 Yes No 06 MED Major gastrointestinal disorders & peritoneal 1.1109 " $9,912.32 " infections w/o CC/MCC374 Yes No 06 MED Digestive malignancy w MCC 1.7229 " $15,373.78 "375 Yes No 06 MED Digestive malignancy w CC 1.3337 " $11,900.53 "376 Yes No 06 MED Digestive malignancy w/o CC/MCC 1.0268 " $9,162.45 "377 Yes No 06 MED G.I. hemorrhage w MCC 1.3367 " $11,927.47 "378 Yes No 06 MED G.I. hemorrhage w CC 1.0195 " $9,097.18 "379 Yes No 06 MED G.I. hemorrhage w/o CC/MCC 0.8476 " $7,562.80 "380 Yes No 06 MED Complicated peptic ulcer w MCC 1.4334 " $12,790.37 "381 Yes No 06 MED Complicated peptic ulcer w CC 1.1302 " $10,084.59 "382 Yes No 06 MED Complicated peptic ulcer w/o CC/MCC 0.9662 " $8,621.63 "383 No No 06 MED Uncomplicated peptic ulcer w MCC 1.1024 " $9,836.48 "384 No No 06 MED Uncomplicated peptic ulcer w/o MCC 0.8399 " $7,494.25 "385 No No 06 MED Inflammatory bowel disease w MCC 1.4936 " $13,327.76 "386 No No 06 MED Inflammatory bowel disease w CC 1.0766 " $9,606.40 "387 No No 06 MED Inflammatory bowel disease w/o CC/MCC 0.9488 " $8,466.20 "388 Yes No 06 MED G.I. obstruction w MCC 1.2860 " $11,475.15 "389 Yes No 06 MED G.I. obstruction w CC 0.9533 " $8,506.61 "390 Yes No 06 MED G.I. obstruction w/o CC/MCC 0.7260 " $6,477.85 "391 No No 06 MED "Esophagitis, gastroent & misc digest disorders 0.9565 " $8,534.51 " w MCC"392 No No 06 MED "Esophagitis, gastroent & misc digest disorders 0.7121 " $6,353.75 " w/o MCC"393 No No 06 MED Other digestive system diagnoses w MCC 1.3237 " $11,811.53 "394 No No 06 MED Other digestive system diagnoses w CC 1.0257 " $9,152.19 "395 No No 06 MED Other digestive system diagnoses w/o CC/MCC 0.7874 " $7,025.63 "405 Yes No 07 SURG "Pancreas, liver & shunt procedures w MCC" 4.8273 " $43,074.37 "406 Yes No 07 SURG "Pancreas, liver & shunt procedures w CC" 3.3149 " $29,579.14 "407 Yes No 07 SURG "Pancreas, liver & shunt procedures w/o 2.2443 " $20,026.01 " CC/MCC"408 No No 07 SURG Biliary tract proc except only cholecyst w or w/o 3.8540 " $34,389.33 " c.d.e. w MCC409 No No 07 SURG Biliary tract proc except only cholecyst w or w/o 2.9126 " $25,989.54 " c.d.e. w CC410 No No 07 SURG Biliary tract proc except only cholecyst w or w/o 2.0794 " $18,554.51 " c.d.e. w/o CC/MCC -12-
  • 13. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC411 No No 07 SURG Cholecystectomy w c.d.e. w MCC 3.4128 " $30,452.00 "412 No No 07 SURG Cholecystectomy w c.d.e. w CC 2.6382 " $23,540.48 "413 No No 07 SURG Cholecystectomy w c.d.e. w/o CC/MCC 1.9412 " $17,321.22 "414 Yes No 07 SURG Cholecystectomy except by laparoscope w/o 3.0942 " $27,609.31 " c.d.e. w MCC415 Yes No 07 SURG Cholecystectomy except by laparoscope w/o 2.2749 " $20,299.25 " c.d.e. w CC416 Yes No 07 SURG Cholecystectomy except by laparoscope w/o 1.5398 " $13,739.56 " c.d.e. w/o CC/MCC417 No No 07 SURG Laparoscopic cholecystectomy w/o c.d.e. w 2.1361 " $19,060.54 " MCC418 No No 07 SURG Laparoscopic cholecystectomy w/o c.d.e. w CC 1.7104 " $15,261.53 "419 No No 07 SURG Laparoscopic cholecystectomy w/o c.d.e. w/o 1.2400 " $11,064.16 " CC/MCC420 No No 07 SURG Hepatobiliary diagnostic procedures w MCC 3.4851 " $31,097.58 "421 No No 07 SURG Hepatobiliary diagnostic procedures w CC 2.2557 " $20,127.87 "422 No No 07 SURG Hepatobiliary diagnostic procedures w/o 1.9432 " $17,338.97 " CC/MCC423 No No 07 SURG Other hepatobiliary or pancreas O.R. 3.9593 " $35,328.84 " procedures w MCC424 No No 07 SURG Other hepatobiliary or pancreas O.R. 3.0104 " $26,862.08 " procedures w CC425 No No 07 SURG Other hepatobiliary or pancreas O.R. 2.5812 " $23,032.08 " procedures w/o CC/MCC432 No No 07 MED Cirrhosis & alcoholic hepatitis w MCC 1.5033 " $13,413.81 "433 No No 07 MED Cirrhosis & alcoholic hepatitis w CC 1.1431 " $10,199.69 "434 No No 07 MED Cirrhosis & alcoholic hepatitis w/o CC/MCC 1.0125 " $9,034.16 "435 No No 07 MED Malignancy of hepatobiliary system or pancreas 1.5661 " $13,974.40 " w MCC436 No No 07 MED Malignancy of hepatobiliary system or pancreas 1.2906 " $11,515.85 " w CC437 No No 07 MED Malignancy of hepatobiliary system or pancreas 1.1709 " $10,448.08 " w/o CC/MCC438 No No 07 MED Disorders of pancreas except malignancy w 1.4201 " $12,671.38 " MCC439 No No 07 MED Disorders of pancreas except malignancy w CC 1.0609 " $9,466.24 " -13-
  • 14. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC440 No No 07 MED Disorders of pancreas except malignancy w/o 0.8912 " $7,951.93 " CC/MCC441 Yes No 07 MED "Disorders of liver except malig,cirr,alc hepa w 1.3973 " $12,467.78 " MCC"442 Yes No 07 MED "Disorders of liver except malig,cirr,alc hepa w 1.0935 " $9,757.62 " CC"443 Yes No 07 MED "Disorders of liver except malig,cirr,alc hepa w/o 0.9079 " $8,101.32 " CC/MCC"444 No No 07 MED Disorders of the biliary tract w MCC 1.3744 " $12,263.51 "445 No No 07 MED Disorders of the biliary tract w CC 1.1030 " $9,842.37 "446 No No 07 MED Disorders of the biliary tract w/o CC/MCC 0.8521 " $7,602.93 "453 No No 08 SURG Combined anterior/posterior spinal fusion w 8.4313 " $75,232.86 " MCC454 No No 08 SURG Combined anterior/posterior spinal fusion w CC 6.5810 " $58,722.50 "455 No No 08 SURG Combined anterior/posterior spinal fusion w/o 5.7023 " $50,881.92 " CC/MCC456 No No 08 SURG Spinal fus exc cerv w spinal curv/malig/infec or 6.7669 " $60,381.39 " 9+ fus w MCC457 No No 08 SURG Spinal fus exc cerv w spinal curv/malig/infec or 5.4650 " $48,764.42 " 9+ fus w CC458 No No 08 SURG Spinal fus exc cerv w spinal curv/malig/infec or 4.9437 " $44,113.00 " 9+ fus w/o CC/MCC459 Yes No 08 SURG Spinal fusion except cervical w MCC 4.8679 " $43,436.68 "460 Yes No 08 SURG Spinal fusion except cervical w/o MCC 3.4870 " $31,114.43 "461 No No 08 SURG Bilateral or multiple major joint procs of lower 3.8345 " $34,215.39 " extremity w MCC462 No No 08 SURG Bilateral or multiple major joint procs of lower 3.0993 " $27,655.21 " extremity w/o MCC463 Yes No 08 SURG "Wnd debrid & skn grft exc hand, for musculo- 3.9615 " $35,348.50 " conn tiss dis w MCC"464 Yes No 08 SURG "Wnd debrid & skn grft exc hand, for musculo- 2.8821 " $25,716.56 " conn tiss dis w CC"465 Yes No 08 SURG "Wnd debrid & skn grft exc hand, for musculo- 2.3417 " $20,894.61 " conn tiss dis w/o CC/MCC"466 Yes No 08 SURG Revision of hip or knee replacement w MCC 3.5408 " $31,594.76 "467 Yes No 08 SURG Revision of hip or knee replacement w CC 2.7523 " $24,558.94 " -14-
  • 15. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC468 Yes No 08 SURG Revision of hip or knee replacement w/o 2.4545 " $21,901.52 " CC/MCC469 Yes No 08 SURG Major joint replacement or reattachment of lower 2.6664 " $23,792.36 " extremity w MCC470 Yes No 08 SURG Major joint replacement or reattachment of lower 1.9871 " $17,731.15 " extremity w/o MCC471 No No 08 SURG Cervical spinal fusion w MCC 3.4723 " $30,983.46 "472 No No 08 SURG Cervical spinal fusion w CC 2.4819 " $22,145.96 "473 No No 08 SURG Cervical spinal fusion w/o CC/MCC 1.9446 " $17,351.40 "474 Yes No 08 SURG Amputation for musculoskeletal sys & conn 2.8432 " $25,369.69 " tissue dis w MCC475 Yes No 08 SURG Amputation for musculoskeletal sys & conn 2.1308 " $19,013.31 " tissue dis w CC476 Yes No 08 SURG Amputation for musculoskeletal sys & conn 1.6799 " $14,989.90 " tissue dis w/o CC/MCC477 Yes Yes 08 SURG Biopsies of musculoskeletal system & 2.6555 " $23,695.22 " connective tissue w MCC478 Yes Yes 08 SURG Biopsies of musculoskeletal system & 1.9836 " $17,699.75 " connective tissue w CC479 Yes Yes 08 SURG Biopsies of musculoskeletal system & 1.6784 " $14,976.38 " connective tissue w/o CC/MCC480 Yes Yes 08 SURG Hip & femur procedures except major joint w 2.4027 " $21,439.70 " MCC481 Yes Yes 08 SURG Hip & femur procedures except major joint w CC 1.8485 " $16,494.30 "482 Yes Yes 08 SURG Hip & femur procedures except major joint w/o 1.5644 " $13,959.18 " CC/MCC483 Yes No 08 SURG Major joint & limb reattachment proc of upper 1.9905 " $17,760.90 " extremity w CC/MCC484 Yes No 08 SURG Major joint & limb reattachment proc of upper 1.7376 " $15,504.87 " extremity w/o CC/MCC485 No No 08 SURG Knee procedures w pdx of infection w MCC 2.9362 " $26,199.36 "486 No No 08 SURG Knee procedures w pdx of infection w CC 2.3382 " $20,863.60 "487 No No 08 SURG Knee procedures w pdx of infection w/o 1.7771 " $15,856.80 " CC/MCC488 Yes No 08 SURG Knee procedures w/o pdx of infection w 1.6584 " $14,798.25 " CC/MCC -15-
  • 16. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC489 Yes No 08 SURG Knee procedures w/o pdx of infection w/o 1.4512 " $12,948.75 " CC/MCC490 No No 08 SURG Back & neck proc exc spinal fusion w CC/MCC 1.4912 " $13,305.56 " or disc device/neurostim491 No No 08 SURG Back & neck proc exc spinal fusion w/o 1.0066 " $8,981.55 " CC/MCC492 Yes Yes 08 SURG "Lower extrem & humer proc except 2.2413 " $19,999.18 " hip,foot,femur w MCC"493 Yes Yes 08 SURG "Lower extrem & humer proc except 1.7186 " $15,335.22 " hip,foot,femur w CC"494 Yes Yes 08 SURG "Lower extrem & humer proc except 1.2752 " $11,378.96 " hip,foot,femur w/o CC/MCC"495 Yes No 08 SURG Local excision & removal int fix devices exc hip 2.5765 " $22,990.31 " & femur w MCC496 Yes No 08 SURG Local excision & removal int fix devices exc hip 1.7792 " $15,875.91 " & femur w CC497 Yes No 08 SURG Local excision & removal int fix devices exc hip 1.2301 " $10,976.37 " & femur w/o CC/MCC498 No No 08 SURG Local excision & removal int fix devices of hip & 1.7563 " $15,671.31 " femur w CC/MCC499 No No 08 SURG Local excision & removal int fix devices of hip & 1.1887 " $10,606.78 " femur w/o CC/MCC500 Yes Yes 08 SURG Soft tissue procedures w MCC 2.4096 " $21,500.49 "501 Yes Yes 08 SURG Soft tissue procedures w CC 1.5598 " $13,918.05 "502 Yes Yes 08 SURG Soft tissue procedures w/o CC/MCC 1.0342 " $9,228.53 "503 No No 08 SURG Foot procedures w MCC 1.7538 " $15,649.11 "504 No No 08 SURG Foot procedures w CC 1.4058 " $12,543.51 "505 No No 08 SURG Foot procedures w/o CC/MCC 1.1584 " $10,336.49 "506 No No 08 SURG Major thumb or joint procedures 1.0877 " $9,705.54 "507 No No 08 SURG Major shoulder or elbow joint procedures w CC/ 1.4296 " $12,756.67 " MCC508 No No 08 SURG Major shoulder or elbow joint procedures w/o 1.1330 " $10,109.71 " CC/MCC509 No No 08 SURG Arthroscopy 1.0769 " $9,609.36 "510 Yes No 08 SURG "Shoulder,elbow or forearm proc,exc major joint 1.6616 " $14,826.72 " proc w MCC" -16-
  • 17. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC511 Yes No 08 SURG "Shoulder,elbow or forearm proc,exc major joint 1.2512 " $11,164.13 " proc w CC"512 Yes No 08 SURG "Shoulder,elbow or forearm proc,exc major joint 0.9602 " $8,567.48 " proc w/o CC/MCC"513 No No 08 SURG "Hand or wrist proc, except major thumb or joint 1.1748 " $10,482.32 " proc w CC/MCC"514 No No 08 SURG "Hand or wrist proc, except major thumb or joint 0.8313 " $7,417.35 " proc w/o CC/MCC"515 Yes Yes 08 SURG Other musculoskelet sys & conn tiss O.R. proc 2.4858 " $22,180.52 " w MCC516 Yes Yes 08 SURG Other musculoskelet sys & conn tiss O.R. proc 1.8307 " $16,335.13 " w CC517 Yes Yes 08 SURG Other musculoskelet sys & conn tiss O.R. proc 1.4192 " $12,663.67 " w/o CC/MCC533 Yes No 08 MED Fractures of femur w MCC 1.1294 " $10,077.98 "534 Yes No 08 MED Fractures of femur w/o MCC 0.7560 " $6,746.05 "535 Yes No 08 MED Fractures of hip & pelvis w MCC 1.0836 " $9,669.38 "536 Yes No 08 MED Fractures of hip & pelvis w/o MCC 0.7340 " $6,549.25 "537 No No 08 MED "Sprains, strains, & dislocations of hip, pelvis & 0.7528 " $6,717.60 " thigh w CC/MCC"538 No No 08 MED "Sprains, strains, & dislocations of hip, pelvis & 0.5986 " $5,341.11 " thigh w/o CC/MCC"539 Yes No 08 MED Osteomyelitis w MCC 1.7648 " $15,747.10 "540 Yes No 08 MED Osteomyelitis w CC 1.4026 " $12,515.04 "541 Yes No 08 MED Osteomyelitis w/o CC/MCC 1.2101 " $10,797.86 "542 Yes No 08 MED Pathological fractures & musculoskelet & conn 1.4877 " $13,274.34 " tiss malig w MCC543 Yes No 08 MED Pathological fractures & musculoskelet & conn 1.1151 " $9,949.68 " tiss malig w CC544 Yes No 08 MED Pathological fractures & musculoskelet & conn 0.9395 " $8,382.97 " tiss malig w/o CC/MCC545 Yes No 08 MED Connective tissue disorders w MCC 1.8330 " $16,355.85 "546 Yes No 08 MED Connective tissue disorders w CC 1.2092 " $10,789.85 "547 Yes No 08 MED Connective tissue disorders w/o CC/MCC 0.9054 " $8,078.77 "548 No No 08 MED Septic arthritis w MCC 1.5372 " $13,716.10 "549 No No 08 MED Septic arthritis w CC 1.1522 " $10,281.04 " -17-
  • 18. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC550 No No 08 MED Septic arthritis w/o CC/MCC 0.9567 " $8,536.89 "551 Yes No 08 MED Medical back problems w MCC 1.1632 " $10,379.22 "552 Yes No 08 MED Medical back problems w/o MCC 0.7839 " $6,994.90 "553 No No 08 MED Bone diseases & arthropathies w MCC 0.9199 " $8,208.17 "554 No No 08 MED Bone diseases & arthropathies w/o MCC 0.6475 " $5,777.90 "555 No No 08 MED Signs & symptoms of musculoskeletal system & 0.7886 " $7,036.53 " conn tissue w MCC556 No No 08 MED Signs & symptoms of musculoskeletal system & 0.5958 " $5,316.59 " conn tissue w/o MCC557 Yes No 08 MED "Tendonitis, myositis & bursitis w MCC" 1.2171 " $10,860.18 "558 Yes No 08 MED "Tendonitis, myositis & bursitis w/o MCC" 0.8480 " $7,566.31 "559 Yes No 08 MED "Aftercare, musculoskeletal system & 1.2104 " $10,800.61 " connective tissue w MCC"560 Yes No 08 MED "Aftercare, musculoskeletal system & 0.8521 " $7,603.73 " connective tissue w CC"561 Yes No 08 MED "Aftercare, musculoskeletal system & 0.6753 " $6,025.83 " connective tissue w/o CC/MCC"562 Yes No 08 MED "Fx, sprn, strn & disl except femur, hip, pelvis & 1.1163 " $9,961.05 " thigh w MCC"563 Yes No 08 MED "Fx, sprn, strn & disl except femur, hip, pelvis & 0.6981 " $6,228.71 " thigh w/o MCC"564 No No 08 MED Other musculoskeletal sys & connective tissue 1.1606 " $10,356.27 " diagnoses w MCC565 No No 08 MED Other musculoskeletal sys & connective tissue 0.9003 " $8,033.14 " diagnoses w CC566 No No 08 MED Other musculoskeletal sys & connective tissue 0.7790 " $6,951.34 " diagnoses w/o CC/MCC573 Yes No 09 SURG Skin graft &/or debrid for skn ulcer or cellulitis w 2.7483 " $24,522.79 " MCC574 Yes No 09 SURG Skin graft &/or debrid for skn ulcer or cellulitis w 2.0177 " $18,004.24 " CC575 Yes No 09 SURG Skin graft &/or debrid for skn ulcer or cellulitis w/ 1.4216 " $12,685.25 " o CC/MCC576 No No 09 SURG Skin graft &/or debrid exc for skin ulcer or 2.4766 " $22,098.54 " cellulitis w MCC -18-
  • 19. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC577 No No 09 SURG Skin graft &/or debrid exc for skin ulcer or 1.6262 " $14,510.59 " cellulitis w CC578 No No 09 SURG Skin graft &/or debrid exc for skin ulcer or 1.0742 " $9,585.46 " cellulitis w/o CC/MCC579 Yes No 09 SURG "Other skin, subcut tiss & breast proc w MCC" 2.3093 " $20,605.96 "580 Yes No 09 SURG "Other skin, subcut tiss & breast proc w CC" 1.4256 " $12,720.84 "581 Yes No 09 SURG "Other skin, subcut tiss & breast proc w/o 0.9124 " $8,141.68 " CC/MCC"582 No No 09 SURG Mastectomy for malignancy w CC/MCC 0.9432 " $8,415.81 "583 No No 09 SURG Mastectomy for malignancy w/o CC/MCC 0.7523 " $6,713.13 "584 No No 09 SURG "Breast biopsy, local excision & other breast 1.2484 " $11,139.29 " procedures w CC/MCC"585 No No 09 SURG "Breast biopsy, local excision & other breast 0.9066 " $8,089.21 " procedures w/o CC/MCC"592 Yes No 09 MED Skin ulcers w MCC 1.4555 " $12,987.16 "593 Yes No 09 MED Skin ulcers w CC 1.1060 " $9,868.56 "594 Yes No 09 MED Skin ulcers w/o CC/MCC 0.9335 " $8,329.40 "595 No No 09 MED Major skin disorders w MCC 1.3997 " $12,489.37 "596 No No 09 MED Major skin disorders w/o MCC 0.8766 " $7,821.92 "597 No No 09 MED Malignant breast disorders w MCC 1.4034 " $12,522.45 "598 No No 09 MED Malignant breast disorders w CC 1.0695 " $9,542.98 "599 No No 09 MED Malignant breast disorders w/o CC/MCC 0.7232 " $6,452.73 "600 No No 09 MED Non-malignant breast disorders w CC/MCC 0.8471 " $7,558.64 "601 No No 09 MED Non-malignant breast disorders w/o CC/MCC 0.6715 " $5,991.84 "602 Yes No 09 MED Cellulitis w MCC 1.1522 " $10,280.76 "603 Yes No 09 MED Cellulitis w/o MCC 0.8087 " $7,215.64 "604 No No 09 MED "Trauma to the skin, subcut tiss & breast w 0.9681 " $8,638.44 " MCC"605 No No 09 MED "Trauma to the skin, subcut tiss & breast w/o 0.6863 " $6,123.92 " MCC"606 No No 09 MED Minor skin disorders w MCC 0.9223 " $8,229.25 "607 No No 09 MED Minor skin disorders w/o MCC 0.6505 " $5,804.09 "614 No No 10 SURG Adrenal & pituitary procedures w CC/MCC 2.1978 " $19,610.57 "615 No No 10 SURG Adrenal & pituitary procedures w/o CC/MCC 1.6502 " $14,724.35 "616 Yes No 10 SURG "Amputat of lower limb for endocrine,nutrit,& 3.1449 " $28,061.74 " metabol dis w MCC" -19-
  • 20. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC617 Yes No 10 SURG "Amputat of lower limb for endocrine,nutrit,& 2.2071 " $19,694.33 " metabol dis w CC"618 Yes No 10 SURG "Amputat of lower limb for endocrine,nutrit,& 1.7554 " $15,663.87 " metabol dis w/o CC/MCC"619 No No 10 SURG O.R. procedures for obesity w MCC 2.7625 " $24,649.82 "620 No No 10 SURG O.R. procedures for obesity w CC 1.9294 " $17,215.71 "621 No No 10 SURG O.R. procedures for obesity w/o CC/MCC 1.6876 " $15,058.80 "622 Yes No 10 SURG "Skin grafts & wound debrid for endoc, nutrit & 2.7257 " $24,321.03 " metab dis w MCC"623 Yes No 10 SURG "Skin grafts & wound debrid for endoc, nutrit & 2.0065 " $17,903.89 " metab dis w CC"624 Yes No 10 SURG "Skin grafts & wound debrid for endoc, nutrit & 1.6056 " $14,326.51 " metab dis w/o CC/MCC"625 No No 10 SURG "Thyroid, parathyroid & thyroglossal procedures 1.5928 " $14,212.32 " w MCC"626 No No 10 SURG "Thyroid, parathyroid & thyroglossal procedures 1.0183 " $9,085.86 " w CC"627 No No 10 SURG "Thyroid, parathyroid & thyroglossal procedures 0.8169 " $7,288.93 " w/o CC/MCC"628 Yes No 10 SURG "Other endocrine, nutrit & metab O.R. proc w 3.0602 " $27,306.48 " MCC"629 Yes No 10 SURG "Other endocrine, nutrit & metab O.R. proc w 2.4730 " $22,066.63 " CC"630 Yes No 10 SURG "Other endocrine, nutrit & metab O.R. proc w/o 1.7767 " $15,853.16 " CC/MCC"637 Yes No 10 MED Diabetes w MCC 1.0891 " $9,718.01 "638 Yes No 10 MED Diabetes w CC 0.8021 " $7,157.57 "639 Yes No 10 MED Diabetes w/o CC/MCC 0.6742 " $6,016.31 "640 Yes No 10 MED Nutritional & misc metabolic disorders w MCC 0.9793 " $8,738.26 "641 Yes No 10 MED Nutritional & misc metabolic disorders w/o MCC 0.7248 " $6,467.70 "642 No No 10 MED Inborn errors of metabolism 1.0616 " $9,473.09 "643 Yes No 10 MED Endocrine disorders w MCC 1.3926 " $12,426.05 "644 Yes No 10 MED Endocrine disorders w CC 1.0638 " $9,492.10 "645 Yes No 10 MED Endocrine disorders w/o CC/MCC 0.8310 " $7,414.96 "652 No No 11 SURG Kidney transplant 3.0654 " $27,352.47 "653 Yes No 11 SURG Major bladder procedures w MCC 4.5710 " $40,787.42 " -20-
  • 21. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC654 Yes No 11 SURG Major bladder procedures w CC 3.1860 " $28,428.52 "655 Yes No 11 SURG Major bladder procedures w/o CC/MCC 2.7075 " $24,158.82 "656 No No 11 SURG Kidney & ureter procedures for neoplasm w 2.6603 " $23,738.25 " MCC657 No No 11 SURG Kidney & ureter procedures for neoplasm w CC 1.8997 " $16,951.45 "658 No No 11 SURG Kidney & ureter procedures for neoplasm w/o 1.6556 " $14,772.63 " CC/MCC659 Yes No 11 SURG Kidney & ureter procedures for non-neoplasm w 2.8119 " $25,090.77 " MCC660 Yes No 11 SURG Kidney & ureter procedures for non-neoplasm w 2.0605 " $18,385.99 " CC661 Yes No 11 SURG Kidney & ureter procedures for non-neoplasm 1.4004 " $12,495.94 " w/o CC/MCC662 No No 11 SURG Minor bladder procedures w MCC 2.0375 " $18,180.35 "663 No No 11 SURG Minor bladder procedures w CC 1.4254 " $12,718.71 "664 No No 11 SURG Minor bladder procedures w/o CC/MCC 1.0388 " $9,268.80 "665 No No 11 SURG Prostatectomy w MCC 2.1393 " $19,089.41 "666 No No 11 SURG Prostatectomy w CC 1.4691 " $13,109.00 "667 No No 11 SURG Prostatectomy w/o CC/MCC 0.9335 " $8,329.30 "668 No No 11 SURG Transurethral procedures w MCC 1.7208 " $15,354.90 "669 No No 11 SURG Transurethral procedures w CC 1.2079 " $10,778.34 "670 No No 11 SURG Transurethral procedures w/o CC/MCC 0.8838 " $7,886.41 "671 No No 11 SURG Urethral procedures w CC/MCC 1.2808 " $11,428.89 "672 No No 11 SURG Urethral procedures w/o CC/MCC 0.8422 " $7,514.74 "673 No No 11 SURG Other kidney & urinary tract procedures w MCC 2.5235 " $22,517.15 "674 No No 11 SURG Other kidney & urinary tract procedures w CC 2.1024 " $18,760.05 "675 No No 11 SURG Other kidney & urinary tract procedures w/o CC/ 1.7196 " $15,343.87 " MCC682 Yes No 11 MED Renal failure w MCC 1.4664 " $13,084.37 "683 Yes No 11 MED Renal failure w CC 1.1942 " $10,655.55 "684 Yes No 11 MED Renal failure w/o CC/MCC 0.9835 " $8,776.18 "685 No No 11 MED Admit for renal dialysis 0.8599 " $7,673.20 "686 No No 11 MED Kidney & urinary tract neoplasms w MCC 1.4513 " $12,949.85 "687 No No 11 MED Kidney & urinary tract neoplasms w CC 1.1147 " $9,946.30 "688 No No 11 MED Kidney & urinary tract neoplasms w/o CC/MCC 0.8577 " $7,652.84 "689 Yes No 11 MED Kidney & urinary tract infections w MCC 1.0587 " $9,446.49 " -21-
  • 22. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC690 Yes No 11 MED Kidney & urinary tract infections w/o MCC 0.8000 " $7,138.62 "691 No No 11 MED Urinary stones w esw lithotripsy w CC/MCC 1.1508 " $10,268.19 "692 No No 11 MED Urinary stones w esw lithotripsy w/o CC/MCC 0.9457 " $8,438.88 "693 No No 11 MED Urinary stones w/o esw lithotripsy w MCC 1.0459 " $9,332.64 "694 No No 11 MED Urinary stones w/o esw lithotripsy w/o MCC 0.7110 " $6,343.89 "695 No No 11 MED Kidney & urinary tract signs & symptoms w 0.9422 " $8,407.53 " MCC696 No No 11 MED Kidney & urinary tract signs & symptoms w/o 0.6276 " $5,600.12 " MCC697 No No 11 MED Urethral stricture 0.7223 " $6,445.07 "698 Yes No 11 MED Other kidney & urinary tract diagnoses w MCC 1.3017 " $11,615.09 "699 Yes No 11 MED Other kidney & urinary tract diagnoses w CC 1.0352 " $9,237.45 "700 Yes No 11 MED Other kidney & urinary tract diagnoses w/o CC/ 0.8232 " $7,345.16 " MCC707 No No 12 SURG Major male pelvic procedures w CC/MCC 1.5521 " $13,849.13 "708 No No 12 SURG Major male pelvic procedures w/o CC/MCC 1.1858 " $10,581.32 "709 No No 12 SURG Penis procedures w CC/MCC 1.6134 " $14,396.54 "710 No No 12 SURG Penis procedures w/o CC/MCC 1.2986 " $11,586.96 "711 No No 12 SURG Testes procedures w CC/MCC 1.6051 " $14,322.11 "712 No No 12 SURG Testes procedures w/o CC/MCC 1.0842 " $9,674.19 "713 No No 12 SURG Transurethral prostatectomy w CC/MCC 0.9850 " $8,789.32 "714 No No 12 SURG Transurethral prostatectomy w/o CC/MCC 0.6710 " $5,987.34 "715 No No 12 SURG Other male reproductive system O.R. proc for 1.5300 " $13,652.12 " malignancy w CC/MCC716 No No 12 SURG Other male reproductive system O.R. proc for 1.1310 " $10,092.04 " malignancy w/o CC/MCC717 No No 12 SURG Other male reproductive system O.R. proc exc 1.5653 " $13,967.27 " malignancy w CC/MCC718 No No 12 SURG Other male reproductive system O.R. proc exc 1.0329 " $9,216.77 " malignancy w/o CC/MCC722 No No 12 MED "Malignancy, male reproductive system w MCC" 1.2827 " $11,445.29 "723 No No 12 MED "Malignancy, male reproductive system w CC" 1.0603 " $9,460.63 "724 No No 12 MED "Malignancy, male reproductive system w/o CC/ 0.7677 " $6,850.23 " MCC"725 No No 12 MED Benign prostatic hypertrophy w MCC 0.9071 " $8,094.07 "726 No No 12 MED Benign prostatic hypertrophy w/o MCC 0.6886 " $6,144.32 " -22-
  • 23. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC727 No No 12 MED Inflammation of the male reproductive system w 1.0083 " $8,997.36 " MCC728 No No 12 MED Inflammation of the male reproductive system w/ 0.7241 " $6,461.12 " o MCC729 No No 12 MED Other male reproductive system diagnoses w 0.9542 " $8,514.35 " CC/MCC730 No No 12 MED Other male reproductive system diagnoses w/o 0.7058 " $6,298.21 " CC/MCC734 No No 13 SURG "Pelvic evisceration, rad hysterectomy & rad 2.0185 " $18,011.05 " vulvectomy w CC/MCC"735 No No 13 SURG "Pelvic evisceration, rad hysterectomy & rad 1.3798 " $12,311.59 " vulvectomy w/o CC/MCC"736 No No 13 SURG Uterine & adnexa proc for ovarian or adnexal 3.2108 " $28,650.29 " malignancy w MCC737 No No 13 SURG Uterine & adnexa proc for ovarian or adnexal 2.1022 " $18,758.24 " malignancy w CC738 No No 13 SURG Uterine & adnexa proc for ovarian or adnexal 1.6754 " $14,949.22 " malignancy w/o CC/MCC739 No No 13 SURG "Uterine,adnexa proc for non-ovarian/adnexal 2.2081 " $19,703.03 " malig w MCC"740 No No 13 SURG "Uterine,adnexa proc for non-ovarian/adnexal 1.4577 " $13,006.62 " malig w CC"741 No No 13 SURG "Uterine,adnexa proc for non-ovarian/adnexal 1.0308 " $9,198.13 " malig w/o CC/MCC"742 No No 13 SURG Uterine & adnexa proc for non-malignancy w 1.2422 " $11,084.10 " CC/MCC743 No No 13 SURG Uterine & adnexa proc for non-malignancy w/o 0.8672 " $7,738.00 " CC/MCC744 No No 13 SURG "D&C, conization, laparascopy & tubal 1.1896 " $10,614.91 " interruption w CC/MCC"745 No No 13 SURG "D&C, conization, laparascopy & tubal 0.8660 " $7,727.32 " interruption w/o CC/MCC"746 No No 13 SURG "Vagina, cervix & vulva procedures w CC/MCC" 1.0488 " $9,358.80 "747 No No 13 SURG "Vagina, cervix & vulva procedures w/o 0.8499 " $7,583.36 " CC/MCC" -23-
  • 24. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC748 No No 13 SURG Female reproductive system reconstructive 0.7916 " $7,063.03 " procedures749 No No 13 SURG Other female reproductive system O.R. 2.2813 " $20,356.30 " procedures w CC/MCC750 No No 13 SURG Other female reproductive system O.R. 1.4993 " $13,378.60 " procedures w/o CC/MCC754 No No 13 MED "Malignancy, female reproductive system w 1.5596 " $13,916.48 " MCC"755 No No 13 MED "Malignancy, female reproductive system w CC" 1.1608 " $10,357.92 "756 No No 13 MED "Malignancy, female reproductive system w/o 0.7702 " $6,872.66 " CC/MCC"757 No No 13 MED "Infections, female reproductive system w MCC" 1.4328 " $12,784.46 "758 No No 13 MED "Infections, female reproductive system w CC" 1.1147 " $9,946.09 "759 No No 13 MED "Infections, female reproductive system w/o CC/ 0.9609 " $8,574.24 " MCC"760 No No 13 MED Menstrual & other female reproductive system 0.6910 " $6,165.84 " disorders w CC/MCC761 No No 13 MED Menstrual & other female reproductive system 0.5569 " $4,969.41 " disorders w/o CC/MCC765 No No 14 SURG Cesarean section w CC/MCC 0.9943 " $8,871.96 "766 No No 14 SURG Cesarean section w/o CC/MCC 0.7664 " $6,838.72 "767 No No 14 SURG Vaginal delivery w sterilization &/or D&C 0.7246 " $6,465.31 "768 No No 14 SURG Vaginal delivery w O.R. proc except steril &/or 1.7348 " $15,479.78 " D&C769 No No 14 SURG Postpartum & post abortion diagnoses w O.R. 1.9114 " $17,055.74 " procedure770 No No 14 SURG "Abortion w D&C, aspiration curettage or 0.7336 " $6,546.07 " hysterotomy"774 No No 14 MED Vaginal delivery w complicating diagnoses 0.5914 " $5,276.68 "775 No No 14 MED Vaginal delivery w/o complicating diagnoses 0.4461 " $3,980.36 "776 No No 14 MED Postpartum & post abortion diagnoses w/o O.R. 0.6460 " $5,763.85 " procedure777 No No 14 MED Ectopic pregnancy 0.7087 " $6,323.92 "778 No No 14 MED Threatened abortion 0.3744 " $3,340.33 "779 No No 14 MED Abortion w/o D&C 0.6013 " $5,365.52 "780 No No 14 MED False labor 0.2845 " $2,538.24 " -24-
  • 25. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC781 No No 14 MED Other antepartum diagnoses w medical 0.5689 " $5,076.74 " complications782 No No 14 MED Other antepartum diagnoses w/o medical 0.4297 " $3,834.09 " complications789 No No 15 MED "Neonates, died or transferred to another acute 1.4250 " $12,715.12 " care facility"790 No No 15 MED "Extreme immaturity or respiratory distress 4.6990 " $41,929.17 " syndrome, neonate"791 No No 15 MED Prematurity w major problems 3.2093 " $28,636.29 "792 No No 15 MED Prematurity w/o major problems 1.9364 " $17,278.58 "793 No No 15 MED Full term neonate w major problems 3.2966 " $29,415.94 "794 No No 15 MED Neonate w other significant problems 1.1668 " $10,411.31 "795 No No 15 MED Normal newborn 0.1580 " $1,409.69 "799 No No 16 SURG Splenectomy w MCC 3.9513 " $35,257.60 "800 No No 16 SURG Splenectomy w CC 2.7617 " $24,642.86 "801 No No 16 SURG Splenectomy w/o CC/MCC 2.3252 " $20,747.76 "802 No No 16 SURG Other O.R. proc of the blood & blood forming 2.7940 " $24,930.69 " organs w MCC803 No No 16 SURG Other O.R. proc of the blood & blood forming 1.8259 " $16,292.34 " organs w CC804 No No 16 SURG Other O.R. proc of the blood & blood forming 1.4754 " $13,164.88 " organs w/o CC/MCC808 No No 16 MED Major hematol/immun diag exc sickle cell crisis 1.6171 " $14,429.62 " & coagul w MCC809 No No 16 MED Major hematol/immun diag exc sickle cell crisis 1.2031 " $10,735.27 " & coagul w CC810 No No 16 MED Major hematol/immun diag exc sickle cell crisis 1.0741 " $9,584.06 " & coagul w/o CC/MCC811 No No 16 MED Red blood cell disorders w MCC 1.0006 " $8,928.25 "812 No No 16 MED Red blood cell disorders w/o MCC 0.7780 " $6,942.24 "813 No No 16 MED Coagulation disorders 1.3426 " $11,980.28 "814 No No 16 MED Reticuloendothelial & immunity disorders w 1.3226 " $11,801.75 " MCC815 No No 16 MED Reticuloendothelial & immunity disorders w CC 1.0233 " $9,130.51 "816 No No 16 MED Reticuloendothelial & immunity disorders w/o 0.7990 " $7,129.52 " CC/MCC -25-
  • 26. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC820 No No 17 SURG Lymphoma & leukemia w major O.R. procedure 4.4970 " $40,126.69 " w MCC821 No No 17 SURG Lymphoma & leukemia w major O.R. procedure 2.6847 " $23,955.28 " w CC822 No No 17 SURG Lymphoma & leukemia w major O.R. procedure 1.5989 " $14,267.29 " w/o CC/MCC823 No No 17 SURG Lymphoma & non-acute leukemia w other O.R. 3.5188 " $31,398.62 " proc w MCC824 No No 17 SURG Lymphoma & non-acute leukemia w other O.R. 2.5164 " $22,454.05 " proc w CC825 No No 17 SURG Lymphoma & non-acute leukemia w other O.R. 1.6201 " $14,455.95 " proc w/o CC/MCC826 No No 17 SURG Myeloprolif disord or poorly diff neopl w maj 3.9780 " $35,495.94 " O.R. proc w MCC827 No No 17 SURG Myeloprolif disord or poorly diff neopl w maj 2.4230 " $21,620.60 " O.R. proc w CC828 No No 17 SURG Myeloprolif disord or poorly diff neopl w maj 1.5109 " $13,481.90 " O.R. proc w/o CC/MCC829 No No 17 SURG Myeloprolif disord or poorly diff neopl w other 2.4894 " $22,213.02 " O.R. proc w CC/MCC830 No No 17 SURG Myeloprolif disord or poorly diff neopl w other 1.6396 " $14,630.00 " O.R. proc w/o CC/MCC834 No No 17 MED Acute leukemia w/o major O.R. procedure w 3.6361 " $32,445.25 " MCC835 No No 17 MED Acute leukemia w/o major O.R. procedure w CC 2.5626 " $22,866.04 "836 No No 17 MED Acute leukemia w/o major O.R. procedure w/o 2.1785 " $19,439.13 " CC/MCC837 No No 17 MED Chemo w acute leukemia as sdx or w high dose 4.7788 " $42,641.12 " chemo agent w MCC838 No No 17 MED Chemo w acute leukemia as sdx w CC or high 2.9919 " $26,696.63 " dose chemo agent839 No No 17 MED Chemo w acute leukemia as sdx w/o CC/MCC 2.3980 " $21,397.33 "840 Yes No 17 MED Lymphoma & non-acute leukemia w MCC 2.1454 " $19,143.67 "841 Yes No 17 MED Lymphoma & non-acute leukemia w CC 1.6444 " $14,673.13 "842 Yes No 17 MED Lymphoma & non-acute leukemia w/o CC/MCC 1.2188 " $10,875.63 " -26-
  • 27. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC843 No No 17 MED Other myeloprolif dis or poorly diff neopl diag w 1.6341 " $14,581.48 " MCC844 No No 17 MED Other myeloprolif dis or poorly diff neopl diag w 1.2403 " $11,066.94 " CC845 No No 17 MED Other myeloprolif dis or poorly diff neopl diag w/ 0.9664 " $8,623.03 " o CC/MCC846 No No 17 MED Chemotherapy w/o acute leukemia as 1.6523 " $14,743.56 " secondary diagnosis w MCC847 No No 17 MED Chemotherapy w/o acute leukemia as 1.0296 " $9,186.72 " secondary diagnosis w CC848 No No 17 MED Chemotherapy w/o acute leukemia as 0.9116 " $8,133.82 " secondary diagnosis w/o CC/MCC849 No No 17 MED Radiotherapy 1.2663 " $11,299.00 "853 Yes No 18 SURG Infectious & parasitic diseases w O.R. 5.1840 " $46,256.98 " procedure w MCC854 Yes No 18 SURG Infectious & parasitic diseases w O.R. 3.9291 " $35,059.53 " procedure w CC855 Yes No 18 SURG Infectious & parasitic diseases w O.R. 3.3662 " $30,036.70 " procedure w/o CC/MCC856 Yes No 18 SURG Postoperative or post-traumatic infections w 3.9257 " $35,029.10 " O.R. proc w MCC857 Yes No 18 SURG Postoperative or post-traumatic infections w 2.4919 " $22,234.99 " O.R. proc w CC858 Yes No 18 SURG Postoperative or post-traumatic infections w 2.0996 " $18,734.98 " O.R. proc w/o CC/MCC862 Yes No 18 MED Postoperative & post-traumatic infections w 1.5454 " $13,789.84 " MCC863 Yes No 18 MED Postoperative & post-traumatic infections w/o 1.0560 " $9,422.34 " MCC864 No No 18 MED Fever of unknown origin 0.8240 " $7,352.13 "865 No No 18 MED Viral illness w MCC 1.2074 " $10,773.88 "866 No No 18 MED Viral illness w/o MCC 0.7527 " $6,716.33 "867 Yes No 18 MED Other infectious & parasitic diseases diagnoses 2.1971 " $19,604.71 " w MCC868 Yes No 18 MED Other infectious & parasitic diseases diagnoses 1.5258 " $13,614.85 " w CC -27-
  • 28. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC869 Yes No 18 MED Other infectious & parasitic diseases diagnoses 1.3611 " $12,144.86 " w/o CC/MCC870 Yes No 18 MED Septicemia w MV 96+ hours 5.7579 " $51,378.01 "871 Yes No 18 MED Septicemia w/o MV 96+ hours w MCC 1.7484 " $15,600.78 "872 Yes No 18 MED Septicemia w/o MV 96+ hours w/o MCC 1.3783 " $12,298.26 "876 No No 19 SURG O.R. procedure w principal diagnoses of mental 2.4632 " $21,979.15 " illness880 No No 19 MED Acute adjustment reaction & psychosocial 0.6085 " $5,430.02 " dysfunction881 No No 19 MED Depressive neuroses 0.5198 " $4,638.21 "882 No No 19 MED Neuroses except depressive 0.5685 " $5,072.79 "883 No No 19 MED Disorders of personality & impulse control 0.8999 " $8,029.74 "884 Yes No 19 MED Organic disturbances & mental retardation 0.8431 " $7,523.15 "885 No No 19 MED Psychoses 0.7783 " $6,944.78 "886 No No 19 MED Behavioral & developmental disorders 0.6983 " $6,230.94 "887 No No 19 MED Other mental disorder diagnoses 0.8341 " $7,443.10 "894 No No 20 MED "Alcohol/drug abuse or dependence, left ama" 0.3571 " $3,186.58 "895 No No 20 MED Alcohol/drug abuse or dependence w 0.7557 " $6,743.04 " rehabilitation therapy896 Yes No 20 MED Alcohol/drug abuse or dependence w/o 1.0419 " $9,296.77 " rehabilitation therapy w MCC897 Yes No 20 MED Alcohol/drug abuse or dependence w/o 0.6145 " $5,483.21 " rehabilitation therapy w/o MCC901 No No 21 SURG Wound debridements for injuries w MCC 2.8534 " $25,461.19 "902 No No 21 SURG Wound debridements for injuries w CC 1.8611 " $16,606.50 "903 No No 21 SURG Wound debridements for injuries w/o CC/MCC 1.4966 " $13,354.12 "904 No No 21 SURG Skin grafts for injuries w CC/MCC 2.5246 " $22,526.64 "905 No No 21 SURG Skin grafts for injuries w/o CC/MCC 1.5926 " $14,211.16 "906 No No 21 SURG Hand procedures for injuries 0.9803 " $8,747.35 "907 Yes No 21 SURG Other O.R. procedures for injuries w MCC 3.1030 " $27,688.19 "908 Yes No 21 SURG Other O.R. procedures for injuries w CC 2.1865 " $19,509.95 "909 Yes No 21 SURG Other O.R. procedures for injuries w/o CC/MCC 1.4112 " $12,592.36 "913 No No 21 MED Traumatic injury w MCC 1.0631 " $9,486.32 "914 No No 21 MED Traumatic injury w/o MCC 0.6890 " $6,148.01 "915 No No 21 MED Allergic reactions w MCC 0.8660 " $7,727.17 "916 No No 21 MED Allergic reactions w/o MCC 0.4986 " $4,449.40 " -28-
  • 29. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC917 Yes No 21 MED Poisoning & toxic effects of drugs w MCC 1.1717 " $10,455.42 "918 Yes No 21 MED Poisoning & toxic effects of drugs w/o MCC 0.6886 " $6,144.31 "919 No No 21 MED Complications of treatment w MCC 1.2830 " $11,448.64 "920 No No 21 MED Complications of treatment w CC 0.9797 " $8,742.23 "921 No No 21 MED Complications of treatment w/o CC/MCC 0.7101 " $6,336.21 "922 No No 21 MED "Other injury, poisoning & toxic effect diag w 1.1338 " $10,117.22 " MCC"923 No No 21 MED "Other injury, poisoning & toxic effect diag w/o 0.7071 " $6,309.17 " MCC"927 No No 22 SURG Extensive burns or full thickness burns w MV 12.3042 " $109,790.32 " 96+ hrs w skin graft928 No No 22 SURG Full thickness burn w skin graft or inhal inj w 4.3956 " $39,221.94 " CC/MCC929 No No 22 SURG Full thickness burn w skin graft or inhal inj w/o 2.3533 " $20,998.16 " CC/MCC933 No No 22 MED Extensive burns or full thickness burns w MV 2.6626 " $23,758.07 " 96+ hrs w/o skin graft934 No No 22 MED Full thickness burn w/o skin grft or inhal inj 1.3745 " $12,264.24 "935 No No 22 MED Non-extensive burns 1.1605 " $10,355.26 "939 No No 23 SURG O.R. proc w diagnoses of other contact w health 2.1672 " $19,337.52 " services w MCC940 No No 23 SURG O.R. proc w diagnoses of other contact w health 1.6823 " $15,011.22 " services w CC941 No No 23 SURG O.R. proc w diagnoses of other contact w health 1.3531 " $12,073.38 " services w/o CC/MCC945 Yes No 23 MED Rehabilitation w CC/MCC 1.1005 " $9,819.61 "946 Yes No 23 MED Rehabilitation w/o CC/MCC 1.0143 " $9,050.82 "947 Yes No 23 MED Signs & symptoms w MCC 0.8767 " $7,822.77 "948 Yes No 23 MED Signs & symptoms w/o MCC 0.6542 " $5,837.58 "949 No No 23 MED Aftercare w CC/MCC 0.7323 " $6,534.65 "950 No No 23 MED Aftercare w/o CC/MCC 0.5948 " $5,307.05 "951 No No 23 MED Other factors influencing health status 0.6109 " $5,451.15 "955 No No 24 SURG Craniotomy for multiple significant trauma 5.1028 " $45,531.98 "956 Yes Yes 24 SURG "Limb reattachment, hip & femur proc for 3.4854 " $31,100.06 " multiple significant trauma" -29-
  • 30. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC957 No No 24 SURG Other O.R. procedures for multiple significant 5.7960 " $51,717.78 " trauma w MCC958 No No 24 SURG Other O.R. procedures for multiple significant 4.4786 " $39,962.28 " trauma w CC959 No No 24 SURG Other O.R. procedures for multiple significant 3.6988 " $33,004.04 " trauma w/o CC/MCC963 No No 24 MED Other multiple significant trauma w MCC 2.2985 " $20,509.94 "964 No No 24 MED Other multiple significant trauma w CC 1.7015 " $15,182.53 "965 No No 24 MED Other multiple significant trauma w/o CC/MCC 1.4108 " $12,588.20 "969 No No 25 SURG HIV w extensive O.R. procedure w MCC 5.1395 " $45,859.37 "970 No No 25 SURG HIV w extensive O.R. procedure w/o MCC 3.6849 " $32,880.66 "974 No No 25 MED HIV w major related condition w MCC 2.1382 " $19,078.97 "975 No No 25 MED HIV w major related condition w CC 1.5918 " $14,203.65 "976 No No 25 MED HIV w major related condition w/o CC/MCC 1.3357 " $11,918.30 "977 No No 25 MED HIV w or w/o other related condition 1.0387 " $9,268.09 "981 Yes No SURG Extensive O.R. procedure unrelated to principal 4.5168 " $40,303.32 " diagnosis w MCC982 Yes No SURG Extensive O.R. procedure unrelated to principal 3.5417 " $31,602.17 " diagnosis w CC983 Yes No SURG Extensive O.R. procedure unrelated to principal 2.9737 " $26,534.07 " diagnosis w/o CC/MCC984 No No SURG Prostatic O.R. procedure unrelated to principal 2.7217 " $24,285.59 " diagnosis w MCC985 No No SURG Prostatic O.R. procedure unrelated to principal 2.0865 " $18,617.46 " diagnosis w CC986 No No SURG Prostatic O.R. procedure unrelated to principal 1.6706 " $14,906.61 " diagnosis w/o CC/MCC987 Yes No SURG Non-extensive O.R. proc unrelated to principal 2.8500 " $25,430.74 " diagnosis w MCC988 Yes No SURG Non-extensive O.R. proc unrelated to principal 2.0134 " $17,965.78 " diagnosis w CC989 Yes No SURG Non-extensive O.R. proc unrelated to principal 1.6310 " $14,553.83 " diagnosis w/o CC/MCC998 No No ** Principal diagnosis invalid as discharge #N/A #N/A diagnosis999 No No ** Ungroupable #N/A #N/A -30-
  • 31. 90-351 Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix IVMS- FY08 Final FY08 Final Rule MDC TYPE MS-DRG Title Weights MWC Payment 8923.0DRG Rule Post- Special Pay DRG Acute DRG001 No No PRE SURG Heart transplant or implant of heart assist 23.1117 " $206,225.39 " system w MCC -31-

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