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DRG Relative Weights

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					                                                       Washington State Medicaid
                                                       Inpatient System Rebasing
                                                         Payment Type by DRG


                                                                                                                                 Average
                                              Version 23.0                                              Payment        Relative Length of
 DRG    MDC                                DRG and Description                     Type of Service      Method         Weight     Stay

  1         1   1-CRANIOTOMY AGE >17 W CC                                          DRG               Paid DRG            4.2292       7.8
  2         1   2-CRANIOTOMY AGE >17 W/O CC                                        DRG               Paid DRG            3.3244       5.0
  6         1   6-CARPAL TUNNEL RELEASE                                            SURGICAL          Paid Per Diem          N/A       N/A
  7         1   7-PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W CC               DRG               Paid DRG            1.8408       4.8
  8         1   8-PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W/O CC             DRG               Paid DRG            1.8544       2.9
  9         1   9-SPINAL DISORDERS & INJURIES                                      DRG               Paid DRG            1.1632       3.2
  10        1   10-NERVOUS SYSTEM NEOPLASMS W CC                                   DRG               Paid DRG            1.2075       4.6
  11        1   11-NERVOUS SYSTEM NEOPLASMS W/O CC                                 MEDICAL           Paid Per Diem          N/A       N/A
  12        1   12-DEGENERATIVE NERVOUS SYSTEM DISORDERS                           DRG               Paid DRG            0.9392       4.3
  13        1   13-MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA                          DRG               Paid DRG            0.9680       4.1
  14        1   14-STROKE WITH INFARCT                                             DRG               Paid DRG            1.2827       4.3
  15        1   15-NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT             DRG               Paid DRG            0.9828       3.6
  16        1   16-NONSPECIFIC CEREBROVASCULAR DISORDERS W CC                      MEDICAL           Paid Per Diem          N/A       N/A
  17        1   17-NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC                    MEDICAL           Paid Per Diem          N/A       N/A
  18        1   18-CRANIAL & PERIPHERAL NERVE DISORDERS W CC                       DRG               Paid DRG            0.9768       3.8
  19        1   19-CRANIAL & PERIPHERAL NERVE DISORDERS W/O CC                     DRG               Paid DRG            0.9565       3.5
  20        1   20-NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS                DRG               Paid DRG            1.6013       5.5
  21        1   21-VIRAL MENINGITIS                                                DRG               Paid DRG            0.6216       2.6
  22        1   22-HYPERTENSIVE ENCEPHALOPATHY                                     MEDICAL           Paid Per Diem          N/A       N/A
  23        1   23-NONTRAUMATIC STUPOR & COMA                                      DRG               Paid DRG            0.7803       2.6
  24        1   24-SEIZURE & HEADACHE AGE >17 W CC                                 DRG               Paid DRG            0.8838       3.0
  25        1   25-SEIZURE & HEADACHE AGE >17 W/O CC                               DRG               Paid DRG            1.0654       3.2
  34        1   34-OTHER DISORDERS OF NERVOUS SYSTEM W CC                          DRG               Paid DRG            0.9090       3.3
  35        1   35-OTHER DISORDERS OF NERVOUS SYSTEM W/O CC                        DRG               Paid DRG            0.8974       2.8
  36        2   36-RETINAL PROCEDURES                                              SURGICAL          Paid Per Diem          N/A       N/A
  37        2   37-ORBITAL PROCEDURES                                              SURGICAL          Paid Per Diem          N/A       N/A
  38        2   38-PRIMARY IRIS PROCEDURES                                         SURGICAL          Paid Per Diem          N/A       N/A
  39        2   39-LENS PROCEDURES WITH OR WITHOUT VITRECTOMY                      SURGICAL          Paid Per Diem          N/A       N/A
  40        2   40-EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE >17                     SURGICAL          Paid Per Diem          N/A       N/A
  41        2   41-EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE <18                     SURGICAL          Paid Per Diem          N/A       N/A
  42        2   42-INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS               SURGICAL          Paid Per Diem          N/A       N/A
  43        2   43-HYPHEMA                                                         MEDICAL           Paid Per Diem          N/A       N/A
  44        2   44-ACUTE MAJOR EYE INFECTIONS                                      DRG               Paid DRG            0.6672       2.8
  45        2   45-NEUROLOGICAL EYE DISORDERS                                      DRG               Paid DRG            1.0964       2.8
  46        2   46-OTHER DISORDERS OF THE EYE AGE >17 W CC                         MEDICAL           Paid Per Diem          N/A       N/A
  47        2   47-OTHER DISORDERS OF THE EYE AGE >17 W/O CC                       MEDICAL           Paid Per Diem          N/A       N/A
  48        2   48-OTHER DISORDERS OF THE EYE AGE <18                              DRG               Paid DRG            0.6393       2.5
  49        3   49-MAJOR HEAD & NECK PROCEDURES EXCEPT FOR MALIGNANCY              SURGICAL          Paid Per Diem          N/A       N/A
  50        3   50-SIALOADENECTOMY                                                 SURGICAL          Paid Per Diem          N/A       N/A
  51        3   51-SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY                SURGICAL          Paid Per Diem          N/A       N/A
  52        3   52-CLEFT LIP & PALATE REPAIR                                       DRG               Paid DRG            1.0927       1.6
  53        3   53-SINUS & MASTOID PROCEDURES AGE >17                              DRG               Paid DRG            1.1303       2.6
  54        3   54-SINUS & MASTOID PROCEDURES AGE <18                              SURGICAL          Paid Per Diem          N/A       N/A
  55        3   55-MISCELLANEOUS EAR, NOSE & THROAT PROCEDURES                     DRG               Paid DRG            1.0611       2.2
  56        3   56-RHINOPLASTY                                                     DRG               Paid DRG            1.0559       1.4
  57        3   57-T&A PROC,EXC TONSILLECT &/OR ADENOIDECT ONLY,AGE >17            DRG               Paid DRG            0.7068       2.2
  58        3   58-T&A PROC,EXC TONSILLECT &/OR ADENOIDECT ONLY,AGE <18            DRG               Paid DRG            1.1590       2.9
  59        3   59-TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17                  SURGICAL          Paid Per Diem          N/A       N/A
  60        3   60-TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE <18                  DRG               Paid DRG            0.6040       1.5
  61        3   61-MYRINGOTOMY W TUBE INSERTION AGE >17                            SURGICAL          Paid Per Diem          N/A       N/A
  62        3   62-MYRINGOTOMY W TUBE INSERTION AGE <18                            DRG               Paid DRG            0.6923       1.8
  63        3   63-OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES                 DRG               Paid DRG            1.5052       2.4
  64        3   64-EAR, NOSE, MOUTH & THROAT MALIGNANCY                            MEDICAL           Paid Per Diem          N/A       N/A
  65        3   65-DYSEQUILIBRIUM                                                  DRG               Paid DRG            0.6354       2.3
  66        3   66-EPISTAXIS                                                       MEDICAL           Paid Per Diem          N/A       N/A
  67        3   67-EPIGLOTTITIS                                                    MEDICAL           Paid Per Diem          N/A       N/A
  68        3   68-OTITIS MEDIA & URI AGE >17 W CC                                 DRG               Paid DRG            0.7166       2.7
  69        3   69-OTITIS MEDIA & URI AGE >17 W/O CC                               DRG               Paid DRG            0.4557       1.8
  70        3   70-OTITIS MEDIA & URI AGE <18                                      DRG               Paid DRG            0.5406       2.2
  71        3   71-LARYNGOTRACHEITIS                                               DRG               Paid DRG            0.3886       1.6
  72        3   72-NASAL TRAUMA & DEFORMITY                                        MEDICAL           Paid Per Diem          N/A       N/A




5/16/2012                                                        Page 1 of 12                                     Tentative and Preliminary
                                                      Washington State Medicaid
                                                      Inpatient System Rebasing
                                                        Payment Type by DRG


                                                                                                                                 Average
                                             Version 23.0                                               Payment        Relative Length of
 DRG    MDC                               DRG and Description                      Type of Service      Method         Weight     Stay

   73       3   73-OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE >17               DRG               Paid DRG            0.8148        3.0
   74       3   74-OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE <18               DRG               Paid DRG            0.7310        2.5
   75       4   75-MAJOR CHEST PROCEDURES                                          DRG               Paid DRG            2.7276        6.4
   76       4   76-OTHER RESP SYSTEM O.R. PROCEDURES W CC                          DRG               Paid DRG            1.8907        5.8
   77       4   77-OTHER RESP SYSTEM O.R. PROCEDURES W/O CC                        SURGICAL          Paid Per Diem          N/A       N/A
   78       4   78-PULMONARY EMBOLISM                                              DRG               Paid DRG            1.2008        4.8
   79       4   79-RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W CC             DRG               Paid DRG            1.3252        5.1
   80       4   80-RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W/O CC           DRG               Paid DRG            0.9501        3.6
   82       4   82-RESPIRATORY NEOPLASMS                                           DRG               Paid DRG            1.4265        4.9
   83       4   83-MAJOR CHEST TRAUMA W CC                                         MEDICAL           Paid Per Diem          N/A       N/A
   84       4   84-MAJOR CHEST TRAUMA W/O CC                                       MEDICAL           Paid Per Diem          N/A       N/A
   85       4   85-PLEURAL EFFUSION W CC                                           DRG               Paid DRG            1.2337        4.8
   86       4   86-PLEURAL EFFUSION W/O CC                                         MEDICAL           Paid Per Diem          N/A       N/A
   87       4   87-PULMONARY EDEMA & RESPIRATORY FAILURE                           DRG               Paid DRG            1.2748        4.3
   88       4   88-CHRONIC OBSTRUCTIVE PULMONARY DISEASE                           DRG               Paid DRG            0.9069        3.7
   89       4   89-SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC                        DRG               Paid DRG            0.9732        3.8
   90       4   90-SIMPLE PNEUMONIA & PLEURISY AGE >17 W/O CC                      DRG               Paid DRG            0.6648        2.8
   92       4   92-INTERSTITIAL LUNG DISEASE W CC                                  DRG               Paid DRG            1.1288        4.6
   93       4   93-INTERSTITIAL LUNG DISEASE W/O CC                                MEDICAL           Paid Per Diem          N/A       N/A
   94       4   94-PNEUMOTHORAX W CC                                               DRG               Paid DRG            0.9049        3.4
   95       4   95-PNEUMOTHORAX W/O CC                                             DRG               Paid DRG            0.7437        3.1
   96       4   96-BRONCHITIS & ASTHMA AGE >17 W CC                                DRG               Paid DRG            0.8290        3.2
   97       4   97-BRONCHITIS & ASTHMA AGE >17 W/O CC                              DRG               Paid DRG            0.6492        2.7
   99       4   99-RESPIRATORY SIGNS & SYMPTOMS W CC                               DRG               Paid DRG            0.8840        2.8
  100       4   100-RESPIRATORY SIGNS & SYMPTOMS W/O CC                            DRG               Paid DRG            0.6700        2.2
  101       4   101-OTHER RESPIRATORY SYSTEM DIAGNOSES W CC                        DRG               Paid DRG            0.9765        3.1
  102       4   102-OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC                      DRG               Paid DRG            0.7437        2.2
  103       5   103-HEART TRANSPLANT                                               TRANSPLANT        RCC                    N/A       N/A
  104       5   104-CARDIAC VALVE PROCEDURES W CARDIAC CATH                        DRG               Paid DRG            6.9265       10.6
  105       5   105-CARDIAC VALVE PROCEDURES W/O CARDIAC CATH                      DRG               Paid DRG            6.3169        6.4
  106       5   106-CORONARY BYPASS W PTCA                                         SURGICAL          Paid Per Diem          N/A       N/A
  107       5   107-CORONARY BYPASS W CARDIAC CATH W/O PTCA                        DRG               Paid DRG            5.1282        7.8
  108       5   108-OTHER CARDIOTHORACIC PROC W/O PDX CONG ANOMALY                 DRG               Paid DRG            4.5559        4.6
  109       5   109-CORONARY BYPASS W/O PTCA OR CARDIAC CATH                       DRG               Paid DRG            4.0040        5.8
  110       5   110-MAJOR CARDIOVASCULAR PROCEDURES W CC                           DRG               Paid DRG            3.9909        6.3
  111       5   111-MAJOR CARDIOVASCULAR PROCEDURES W/O CC                         DRG               Paid DRG            2.8338        3.3
  112       5   112-PERCUTANEOUS CARDIOVASC PROC W/O AMI, HFI OR SHOCK             DRG               Paid DRG            2.1559        2.3
  113       5   113-AMPUTAT FOR CIRC SYSTEM DISORD EXCEPT UPPER LIMB & TOE         DRG               Paid DRG            2.8379        9.3
  114       5   114-UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS          SURGICAL          Paid Per Diem          N/A       N/A
  115       5   115-PRM CARD PACEM IMPL W AMI,HRT FAIL OR SHK,OR AICD LEAD OR GN   SURGICAL          Paid Per Diem          N/A       N/A
  116       5   116-OTHER PERMANENT CARDIAC PACEMAKER IMPLANT                      DRG               Paid DRG            2.9608        3.3
  117       5   117-CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT           SURGICAL          Paid Per Diem          N/A       N/A
  118       5   118-CARDIAC PACEMAKER DEVICE REPLACEMENT                           SURGICAL          Paid Per Diem          N/A       N/A
  119       5   119-VEIN LIGATION & STRIPPING                                      SURGICAL          Paid Per Diem          N/A       N/A
  120       5   120-OTHER CIRCULATORY SYSTEM O.R. PROCEDURES                       DRG               Paid DRG            1.7860        6.3
  121       5   121-CIRCULATORY DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE     DRG               Paid DRG            2.1329        5.9
  122       5   122-CIRCULATORY DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE   DRG               Paid DRG            1.2491        3.1
  123       5   123-CIRCULATORY DISORDERS W AMI, EXPIRED                           MEDICAL           Paid Per Diem          N/A       N/A
  124       5   124-CIRC DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG          DRG               Paid DRG            1.5481        3.5
  125       5   125-CIRC DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG        DRG               Paid DRG            1.2296        2.2
  126       5   126-ACUTE & SUBACUTE ENDOCARDITIS                                  DRG               Paid DRG            3.8399       12.9
  127       5   127-HEART FAILURE & SHOCK                                          DRG               Paid DRG            0.9337        3.3
  128       5   128-DEEP VEIN THROMBOPHLEBITIS                                     MEDICAL           Paid Per Diem          N/A       N/A
  129       5   129-CARDIAC ARREST, UNEXPLAINED                                    MEDICAL           Paid Per Diem          N/A       N/A
  130       5   130-PERIPHERAL VASCULAR DISORDERS W CC                             DRG               Paid DRG            1.1801        4.6
  131       5   131-PERIPHERAL VASCULAR DISORDERS W/O CC                           DRG               Paid DRG            1.0058        3.7
  132       5   132-ATHEROSCLEROSIS W CC                                           DRG               Paid DRG            0.7805        2.3
  133       5   133-ATHEROSCLEROSIS W/O CC                                         DRG               Paid DRG            0.5700        1.9
  134       5   134-HYPERTENSION                                                   DRG               Paid DRG            0.7549        2.5
  135       5   135-CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W CC           MEDICAL           Paid Per Diem          N/A       N/A
  136       5   136-CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC         MEDICAL           Paid Per Diem          N/A       N/A




5/16/2012                                                       Page 2 of 12                                      Tentative and Preliminary
                                                      Washington State Medicaid
                                                      Inpatient System Rebasing
                                                        Payment Type by DRG


                                                                                                                                Average
                                             Version 23.0                                              Payment        Relative Length of
 DRG    MDC                               DRG and Description                     Type of Service      Method         Weight     Stay

  137       5   137-CARDIAC CONGENITAL & VALVULAR DISORDERS AGE <18               MEDICAL           Paid Per Diem          N/A       N/A
  138       5   138-CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC                DRG               Paid DRG            0.8762       3.0
  139       5   139-CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC              DRG               Paid DRG            0.6675       2.1
  140       5   140-ANGINA PECTORIS                                               DRG               Paid DRG            0.5881       1.7
  141       5   141-SYNCOPE & COLLAPSE W CC                                       DRG               Paid DRG            0.7146       2.4
  142       5   142-SYNCOPE & COLLAPSE W/O CC                                     DRG               Paid DRG            0.6726       2.3
  143       5   143-CHEST PAIN                                                    DRG               Paid DRG            0.6550       1.8
  144       5   144-OTHER CIRCULATORY SYSTEM DIAGNOSES W CC                       DRG               Paid DRG            1.1491       3.6
  145       5   145-OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC                     DRG               Paid DRG            0.9204       2.7
  146       6   146-RECTAL RESECTION W CC                                         DRG               Paid DRG            2.3269       7.3
  147       6   147-RECTAL RESECTION W/O CC                                       DRG               Paid DRG            2.7648       6.2
  148       6   148-MAJOR SMALL & LARGE BOWEL PROCEDURES W CC                     DRG               Paid DRG            2.7265       8.6
  149       6   149-MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC                   DRG               Paid DRG            2.0972       6.1
  150       6   150-PERITONEAL ADHESIOLYSIS W CC                                  DRG               Paid DRG            2.3209       7.2
  151       6   151-PERITONEAL ADHESIOLYSIS W/O CC                                DRG               Paid DRG            1.0882       3.3
  152       6   152-MINOR SMALL & LARGE BOWEL PROCEDURES W CC                     DRG               Paid DRG            2.2472       6.7
  153       6   153-MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC                   DRG               Paid DRG            1.4177       4.6
  154       6   154-STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC        DRG               Paid DRG            2.5679       6.9
  155       6   155-STOMACH,ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC       DRG               Paid DRG            1.4229       3.1
  156       6   156-STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE <18             DRG               Paid DRG            1.8246       4.4
  157       6   157-ANAL & STOMAL PROCEDURES W CC                                 DRG               Paid DRG            1.1792       3.9
  158       6   158-ANAL & STOMAL PROCEDURES W/O CC                               DRG               Paid DRG            0.9610       2.9
  159       6   159-HERNIA PROCS EXCEPT INGUINAL & FEMORAL AGE >17 W CC           DRG               Paid DRG            1.3658       3.7
  160       6   160-HERNIA PROCS EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC         DRG               Paid DRG            1.0604       2.7
  161       6   161-INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC             DRG               Paid DRG            1.1679       3.0
  162       6   162-INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC           DRG               Paid DRG            1.0708       2.6
  163       6   163-HERNIA PROCEDURES AGE <18                                     DRG               Paid DRG            0.7480       1.5
  164       6   164-APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC                DRG               Paid DRG            2.0621       6.3
  165       6   165-APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC              DRG               Paid DRG            1.3664       4.3
  166       6   166-APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC              DRG               Paid DRG            0.9946       2.6
  167       6   167-APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC            DRG               Paid DRG            0.6781       1.7
  168       3   168-MOUTH PROCEDURES W CC                                         SURGICAL          Paid Per Diem          N/A       N/A
  169       3   169-MOUTH PROCEDURES W/O CC                                       SURGICAL          Paid Per Diem          N/A       N/A
  170       6   170-OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC                   DRG               Paid DRG            2.4450       6.5
  171       6   171-OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC                 DRG               Paid DRG            1.1429       3.5
  172       6   172-DIGESTIVE MALIGNANCY W CC                                     DRG               Paid DRG            1.1807       4.5
  173       6   173-DIGESTIVE MALIGNANCY W/O CC                                   MEDICAL           Paid Per Diem          N/A       N/A
  174       6   174-G.I. HEMORRHAGE W CC                                          DRG               Paid DRG            1.0489       3.2
  175       6   175-G.I. HEMORRHAGE W/O CC                                        DRG               Paid DRG            0.7612       2.3
  176       6   176-COMPLICATED PEPTIC ULCER                                      DRG               Paid DRG            1.0504       3.8
  177       6   177-UNCOMPLICATED PEPTIC ULCER W CC                               DRG               Paid DRG            0.8776       2.8
  178       6   178-UNCOMPLICATED PEPTIC ULCER W/O CC                             DRG               Paid DRG            0.9276       3.1
  179       6   179-INFLAMMATORY BOWEL DISEASE                                    DRG               Paid DRG            1.1557       4.3
  180       6   180-G.I. OBSTRUCTION W CC                                         DRG               Paid DRG            0.8365       3.5
  181       6   181-G.I. OBSTRUCTION W/O CC                                       DRG               Paid DRG            0.7090       2.9
  182       6   182-ESOPHAGITIS,GASTROENT & MISC DIGEST DISORD AGE>17 W CC        DRG               Paid DRG            0.9047       3.4
  183       6   183-ESOPHAGITIS,GASTROENT & MISC DIGEST DISORD AGE>17 W?O CC      DRG               Paid DRG            0.7175       2.7
  185       3   185-DENTAL & ORAL DIS EXC EXTRACT & RESTORATIONS, AGE >17         DRG               Paid DRG            0.6204       2.2
  186       3   186-DENTAL & ORAL DIS EXC EXTRACT & RESTORATIONS, AGE <18         DRG               Paid DRG            0.6127       2.6
  187       3   187-DENTAL EXTRACTIONS & RESTORATIONS                             MEDICAL           Paid Per Diem          N/A       N/A
  188       6   188-OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W CC                 DRG               Paid DRG            0.9477       3.5
  189       6   189-OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W/O CC               DRG               Paid DRG            0.8211       3.2
  191       7   191-PANCREAS, LIVER & SHUNT PROCEDURES W CC                       DRG               Paid DRG            3.4669       8.8
  192       7   192-PANCREAS, LIVER & SHUNT PROCEDURES W/O CC                     DRG               Paid DRG            2.3049       6.2
  193       7   193-BIL TRACT PROC W CC EXC ONLY TOT CHOLECYST OR W/O CDE         DRG               Paid DRG            2.9107       8.2
  194       7   194-BIL TRACT PROC W/O CC EXC ONLY TOT CHOLECYSTECT W/O CDE       SURGICAL          Paid Per Diem          N/A       N/A
  195       7   195-TOTAL CHOLECYSTECTOMY W C.D.E W CC                            SURGICAL          Paid Per Diem          N/A       N/A
  196       7   196-TOTAL CHOLECYSTECTOMY W C.D.E W/O CC                          SURGICAL          Paid Per Diem          N/A       N/A
  197       7   197-TOTAL CHOLECYSTECTOMY W/O C.D.E W CC                          DRG               Paid DRG            1.7960       4.8
  198       7   198-TOTAL CHOLECYSTECTOMY W/O C.D.E W/O CC                        DRG               Paid DRG            1.3783       4.2
  199       7   199-HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY             SURGICAL          Paid Per Diem          N/A       N/A




5/16/2012                                                       Page 3 of 12                                     Tentative and Preliminary
                                                       Washington State Medicaid
                                                       Inpatient System Rebasing
                                                         Payment Type by DRG


                                                                                                                                 Average
                                              Version 23.0                                              Payment        Relative Length of
 DRG    MDC                                DRG and Description                     Type of Service      Method         Weight     Stay

  200       7   200-HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY          SURGICAL          Paid Per Diem          N/A       N/A
  201       7   201-OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES                SURGICAL          Paid Per Diem          N/A       N/A
  202       7   202-CIRRHOSIS & ALCOHOLIC HEPATITIS                                DRG               Paid DRG            1.2403       4.3
  203       7   203-MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS                 DRG               Paid DRG            1.2055       4.4
  204       7   204-DISORDERS OF PANCREAS EXCEPT MALIGNANCY                        DRG               Paid DRG            0.9306       3.8
  205       7   205-DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC             DRG               Paid DRG            1.0165       3.9
  206       7   206-DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC           DRG               Paid DRG            0.9349       3.4
  207       7   207-DISORDERS OF THE BILIARY TRACT W CC                            DRG               Paid DRG            1.2088       4.0
  208       7   208-DISORDERS OF THE BILIARY TRACT W/O CC                          DRG               Paid DRG            0.7352       2.4
  209       8   209-MAJOR JOINT&LIMB REATTACH PROC OF LOW EXT, EXC HIP,EXC COMP    DRG               Paid DRG            2.2165       3.7
  210       8   210-HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC         DRG               Paid DRG            2.3175       6.1
  211       8   211-HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O CC       DRG               Paid DRG            1.6420       3.9
  212       8   212-HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE <18              DRG               Paid DRG            1.9111       3.0
  213       8   213-AMPUTAT FOR MUSCULOSKELET SYSTEM & CONN TISSUE DISORDERS       DRG               Paid DRG            1.6336       5.3
  216       8   216-BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE         SURGICAL          Paid Per Diem          N/A       N/A
  217       8   217-WND DEBRID&SKN GRFT EXC OPEN WND,MS & CONN TIS, EXC HAND       DRG               Paid DRG            3.0480       8.8
  218       8   218-LOW EXTREM & HUMER PROC EXC HIP,FOOT,FEMUR AGE>17 W CC         DRG               Paid DRG            2.1415       5.0
  219       8   219-LOW EXTREM & HUMER PROC EXC HIP,FOOT,FEMUR AGE>17 W/O CC       DRG               Paid DRG            1.3588       2.9
  220       8   220-LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE <18        DRG               Paid DRG            1.2960       2.2
  221       8   221-KNEE PROCEDURES W CC                                           SURGICAL          Paid Per Diem          N/A       N/A
  222       8   222-KNEE PROCEDURES W/O CC                                         DRG               Paid DRG            1.4454       2.6
  223       8   223-MAJ SHOULD/ELBOW PROC, OR OTH UPPER EXTREMITY PROC W CC        DRG               Paid DRG            1.0844       2.4
  224       8   224-SHOULD,ELBOW OR FOREARM PROC,EXC MAJ JOINT PROC, W/O CC        DRG               Paid DRG            0.9142       1.8
  225       8   225-FOOT PROCEDURES                                                DRG               Paid DRG            1.3309       3.4
  226       8   226-SOFT TISSUE PROCEDURES W CC                                    DRG               Paid DRG            1.5638       4.2
  227       8   227-SOFT TISSUE PROCEDURES W/O CC                                  DRG               Paid DRG            1.1725       2.4
  228       8   228-MAJOR THUMB OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC       DRG               Paid DRG            1.3558       4.2
  229       8   229-HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC            DRG               Paid DRG            0.8712       2.5
  230       8   230-LOCAL EXCIS & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR        DRG               Paid DRG            1.3192       3.5
  232       8   232-ARTHROSCOPY                                                    SURGICAL          Paid Per Diem          N/A       N/A
  233       8   233-OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC             DRG               Paid DRG            2.9188       5.0
  234       8   234-OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC           DRG               Paid DRG            2.3987       2.8
  235       8   235-FRACTURES OF FEMUR                                             DRG               Paid DRG            0.7327       2.2
  236       8   236-FRACTURES OF HIP & PELVIS                                      DRG               Paid DRG            1.0419       3.5
  237       8   237-SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH        MEDICAL           Paid Per Diem          N/A       N/A
  238       8   238-OSTEOMYELITIS                                                  DRG               Paid DRG            1.3328       5.2
  239       8   239-PATHOLOGICAL FX & MUSCULOSKELET & CONN TISS MALIGNANCY         DRG               Paid DRG            1.5449       5.4
  240       8   240-CONNECTIVE TISSUE DISORDERS W CC                               DRG               Paid DRG            1.4159       4.9
  241       8   241-CONNECTIVE TISSUE DISORDERS W/O CC                             DRG               Paid DRG            1.1694       2.9
  242       8   242-SEPTIC ARTHRITIS                                               DRG               Paid DRG            1.0912       4.1
  243       8   243-MEDICAL BACK PROBLEMS                                          DRG               Paid DRG            0.8927       3.4
  244       8   244-BONE DISEASES & SPECIFIC ARTHROPATHIES W CC                    MEDICAL           Paid Per Diem          N/A       N/A
  245       8   245-BONE DISEASES & SPECIFIC ARTHROPATHIES W/O CC                  MEDICAL           Paid Per Diem          N/A       N/A
  246       8   246-NON-SPECIFIC ARTHROPATHIES                                     MEDICAL           Paid Per Diem          N/A       N/A
  247       8   247-SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE       DRG               Paid DRG            0.8377       3.1
  248       8   248-TENDONITIS, MYOSITIS & BURSITIS                                DRG               Paid DRG            0.9358       3.7
  249       8   249-MALFUNCTION, REACTION OR COMP OF ORTHOPEDIC DEV OR PROC        MEDICAL           Paid Per Diem          N/A       N/A
  250       8   250-FX,SPRN,STRN & DISL OF FOREARM,HAND,FOOT AGE>17 W CC           MEDICAL           Paid Per Diem          N/A       N/A
  251       8   251-FX,SPRN,STRN & DISL OF FOREARM,HAND,FOOT AGE>17 W/O CC         MEDICAL           Paid Per Diem          N/A       N/A
  252       8   252-FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE <18           DRG               Paid DRG            0.4016       1.3
  253       8   253-FX,SPRN,STRN & DISL UPARM,LOWLEG EX FOOT AGE>17 W CC           DRG               Paid DRG            0.9065       3.5
  254       8   254-FX,SPRN,STRN & DISL UPARM,LOWLEG EX FOOT AGE>17 W/O CC         DRG               Paid DRG            0.6227       2.1
  255       8   255-FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE <18          DRG               Paid DRG            0.5142       2.0
  256       8   256-OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAG          MEDICAL           Paid Per Diem          N/A       N/A
  257       9   257-TOTAL MASTECTOMY FOR MALIGNANCY W CC                           DRG               Paid DRG            0.9349       1.9
  258       9   258-TOTAL MASTECTOMY FOR MALIGNANCY W/O CC                         DRG               Paid DRG            0.9204       1.3
  259       9   259-SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC                        DRG               Paid DRG            1.1128       1.8
  260       9   260-SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC                      DRG               Paid DRG            0.7516       1.0
  261       9   261-BREAST PROC FOR NON-MALIG EXCEPT BIOPSY & LOCAL EXCISION       SURGICAL          Paid Per Diem          N/A       N/A
  262       9   262-BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY              SURGICAL          Paid Per Diem          N/A       N/A
  263       9   263-SKIN GRAFT &/OR DEBRID FOR SKN ULCER, CELLULITIS W CC          DRG               Paid DRG            1.8615       7.3




5/16/2012                                                        Page 4 of 12                                     Tentative and Preliminary
                                                       Washington State Medicaid
                                                       Inpatient System Rebasing
                                                         Payment Type by DRG


                                                                                                                                 Average
                                              Version 23.0                                              Payment        Relative Length of
 DRG    MDC                                DRG and Description                     Type of Service      Method         Weight     Stay

  264        9   264-SKIN GRAFT &/OR DEBRID FOR SKN ULCER, CELLULITIS W/O CC       DRG               Paid DRG            1.3686       5.2
  265        9   265-SKIN GRAFT &/OR DEBRID EXC FOR SKIN ULCER, CELLUL W CC        SURGICAL          Paid Per Diem          N/A       N/A
  266        9   266-SKIN GRAFT &/OR DEBRID EXC FOR SKN ULCER, CELLUL W/O CC       DRG               Paid DRG            1.1454       3.3
  267        9   267-PERIANAL & PILONIDAL PROCEDURES                               SURGICAL          Paid Per Diem          N/A       N/A
  268        9   268-SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES         DRG               Paid DRG            0.9192       1.7
  269        9   269-OTHER SKIN, SUBCUT TISS & BREAST PROCEDURE W CC               DRG               Paid DRG            1.3569       4.8
  270        9   270-OTHER SKIN, SUBCUT TISS & BREAST PROCEDURE W/O CC             DRG               Paid DRG            0.9759       3.0
  271        9   271-SKIN ULCERS                                                   DRG               Paid DRG            1.1441       4.9
  272        9   272-MAJOR SKIN DISORDERS W CC                                     MEDICAL           Paid Per Diem          N/A       N/A
  273        9   273-MAJOR SKIN DISORDERS W/O CC                                   MEDICAL           Paid Per Diem          N/A       N/A
  274        9   274-MALIGNANT BREAST DISORDERS W CC                               MEDICAL           Paid Per Diem          N/A       N/A
  275        9   275-MALIGNANT BREAST DISORDERS W/O CC                             MEDICAL           Paid Per Diem          N/A       N/A
  276        9   276-NON-MALIGANT BREAST DISORDERS                                 DRG               Paid DRG            0.6583       2.9
  277        9   277-CELLULITIS AGE >17 W CC                                       DRG               Paid DRG            0.9365       4.1
  278        9   278-CELLULITIS AGE >17 W/O CC                                     DRG               Paid DRG            0.6051       2.9
  279        9   279-CELLULITIS AGE <18                                            DRG               Paid DRG            0.7509       2.9
  280        9   280-TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W CC         DRG               Paid DRG            0.7113       2.4
  281        9   281-TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC       DRG               Paid DRG            0.6582       2.0
  282        9   282-TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE <18              DRG               Paid DRG            0.5521       1.5
  283        9   283-MINOR SKIN DISORDERS W CC                                     DRG               Paid DRG            0.8160       3.4
  284        9   284-MINOR SKIN DISORDERS W/O CC                                   DRG               Paid DRG            0.6222       2.7
  285       10   285-AMPUTAT OF LOW LIMB FOR ENDOCRINE,NUTRIT& METABOL DISORD      DRG               Paid DRG            2.2335       7.8
  286       10   286-ADRENAL & PITUITARY PROCEDURES                                DRG               Paid DRG            2.2334       4.3
  287       10   287-SKIN GFT & WOUND DEBRID FOR ENDOC,NUTRIT & METAB DISORD       SURGICAL          Paid Per Diem          N/A       N/A
  288       10   288-O.R. PROCEDURES FOR OBESITY                                   DRG               Paid DRG            1.7012       3.4
  289       10   289-PARATHYROID PROCEDURES                                        SURGICAL          Paid Per Diem          N/A       N/A
  290       10   290-THYROID PROCEDURES                                            DRG               Paid DRG            0.8933       1.7
  291       10   291-THYROGLOSSAL PROCEDURES                                       DRG               Paid DRG            0.6743       1.4
  292       10   292-OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC                SURGICAL          Paid Per Diem          N/A       N/A
  293       10   293-OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC              SURGICAL          Paid Per Diem          N/A       N/A
  294       10   294-DIABETES AGE >35                                              DRG               Paid DRG            0.7452       2.8
  295       10   295-DIABETES AGE <36                                              DRG               Paid DRG            0.8097       2.6
  296       10   296-NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC           DRG               Paid DRG            0.7754       3.0
  297       10   297-NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W/O CC         DRG               Paid DRG            0.6483       2.8
  298       10   298-NUTRITIONAL & MISC METABOLIC DISORDERS AGE <18                DRG               Paid DRG            0.5372       2.4
  299       10   299-INBORN ERRORS OF METABOLISM                                   DRG               Paid DRG            1.8195       5.3
  300       10   300-ENDOCRINE DISORDERS W CC                                      DRG               Paid DRG            0.8402       3.1
  301       10   301-ENDOCRINE DISORDERS W/O CC                                    DRG               Paid DRG            0.5603       2.0
  302       11   302-KIDNEY TRANSPLANT                                             TRANSPLANT        RCC                    N/A       N/A
  303       11   303-KIDNEY,URETER & MAJOR BLADDER PROC FOR NEOPLASM               DRG               Paid DRG            2.2685       5.8
  304       11   304-KIDNEY,URETER & MAJOR BLAD PROC FOR NON-NEOPLASM W CC         DRG               Paid DRG            2.1061       4.8
  305       11   305-KIDNEY,URETER & MAJOR BLAD PROC FOR NON-NEOPLASM W/O CC       DRG               Paid DRG            1.4787       3.0
  306       11   306-PROSTATECTOMY W CC                                            SURGICAL          Paid Per Diem          N/A       N/A
  307       11   307-PROSTATECTOMY W/O CC                                          SURGICAL          Paid Per Diem          N/A       N/A
  308       11   308-MINOR BLADDER PROCEDURES W CC                                 DRG               Paid DRG            1.4257       3.1
  309       11   309-MINOR BLADDER PROCEDURES W/O CC                               DRG               Paid DRG            0.8504       1.7
  310       11   310-TRANSURETHRAL PROCEDURES W CC                                 DRG               Paid DRG            0.9627       2.1
  311       11   311-TRANSURETHRAL PROCEDURES W/O CC                               DRG               Paid DRG            0.8176       1.9
  312       11   312-URETHRAL PROCEDURES, AGE >17 W CC                             SURGICAL          Paid Per Diem          N/A       N/A
  313       11   313-URETHRAL PROCEDURES, AGE >17 W/O CC                           SURGICAL          Paid Per Diem          N/A       N/A
  314       11   314-URETHRAL PROCEDURES, AGE <18                                  SURGICAL          Paid Per Diem          N/A       N/A
  315       11   315-OTHER KIDNEY & URINARY TRACT O.R. PROCEDURES                  DRG               Paid DRG            2.2172       5.3
  316       11   316-RENAL FAILURE                                                 DRG               Paid DRG            1.2690       4.4
  317       11   317-ADMIT FOR RENAL DIALYSIS                                      MEDICAL           Paid Per Diem          N/A       N/A
  318       11   318-KIDNEY & URINARY TRACT NEOPLASMS W CC                         MEDICAL           Paid Per Diem          N/A       N/A
  319       11   319-KIDNEY & URINARY TRACT NEOPLASMS W/O CC                       MEDICAL           Paid Per Diem          N/A       N/A
  320       11   320-KIDNEY & URINARY TRACT INFECTIONS AGE >17 W CC                DRG               Paid DRG            0.8071       3.3
  321       11   321-KIDNEY & URINARY TRACT INFECTIONS AGE >17 W/O CC              DRG               Paid DRG            0.6537       2.8
  322       11   322-KIDNEY & URINARY TRACT INFECTIONS AGE <18                     DRG               Paid DRG            0.6680       2.7
  323       11   323-URINARY STONES W CC, &/OR ESW LITHOTRIPSY                     DRG               Paid DRG            0.7324       2.2
  324       11   324-URINARY STONES W/O CC                                         DRG               Paid DRG            0.5645       2.2




5/16/2012                                                        Page 5 of 12                                     Tentative and Preliminary
                                                       Washington State Medicaid
                                                       Inpatient System Rebasing
                                                         Payment Type by DRG


                                                                                                                                 Average
                                              Version 23.0                                              Payment        Relative Length of
 DRG    MDC                                DRG and Description                     Type of Service      Method         Weight     Stay

  325       11   325-KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC          DRG               Paid DRG            0.6974       2.3
  326       11   326-KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC        DRG               Paid DRG            0.3974       1.5
  327       11   327-KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE <18               MEDICAL           Paid Per Diem          N/A       N/A
  328       11   328-URETHRAL STRICTURE AGE >17 W CC                               MEDICAL           Paid Per Diem          N/A       N/A
  329       11   329-URETHRAL STRICTURE AGE >17 W/O CC                             MEDICAL           Paid Per Diem          N/A       N/A
  330       11   330-URETHRAL STRICTURE AGE <18                                    MEDICAL           Paid Per Diem          N/A       N/A
  331       11   331-OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W CC           DRG               Paid DRG            1.1727       4.3
  332       11   332-OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W/O CC         MEDICAL           Paid Per Diem          N/A       N/A
  333       11   333-OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE <18                DRG               Paid DRG            0.8911       3.0
  334       12   334-MAJOR MALE PELVIC PROCEDURES W CC                             SURGICAL          Paid Per Diem          N/A       N/A
  335       12   335-MAJOR MALE PELVIC PROCEDURES W/O CC                           DRG               Paid DRG            1.3717       3.1
  336       12   336-TRANSURETHRAL PROSTATECTOMY W CC                              DRG               Paid DRG            0.6069       1.6
  337       12   337-TRANSURETHRAL PROSTATECTOMY W/O CC                            DRG               Paid DRG            0.6076       1.7
  338       12   338-TESTES PROCEDURES, FOR MALIGNANCY                             SURGICAL          Paid Per Diem          N/A       N/A
  339       12   339-TESTES PROCEDURES, NON-MALIGNANCY AGE >17                     SURGICAL          Paid Per Diem          N/A       N/A
  340       12   340-TESTES PROCEDURES, NON-MALIGNANCY AGE <18                     DRG               Paid DRG            0.8788       1.6
  341       12   341-PENIS PROCEDURES                                              DRG               Paid DRG            1.2193       3.9
  342       12   342-CIRCUMCISION AGE >17                                          SURGICAL          Paid Per Diem          N/A       N/A
  343       12   343-CIRCUMCISION AGE <18                                          SURGICAL          Paid Per Diem          N/A       N/A
  344       12   344-OTHER MALE REPRODUCTIVE SYS O.R. PROCS FOR MALIGNANCY         SURGICAL          Paid Per Diem          N/A       N/A
  345       12   345-OTHER MALE REPRODUCTIVE SYS O.R. PROCS EXCEPT FOR MALIG       SURGICAL          Paid Per Diem          N/A       N/A
  346       12   346-MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC                    MEDICAL           Paid Per Diem          N/A       N/A
  347       12   347-MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC                  MEDICAL           Paid Per Diem          N/A       N/A
  348       12   348-BENIGN PROSTATIC HYPERTROPHY W CC                             MEDICAL           Paid Per Diem          N/A       N/A
  349       12   349-BENIGN PROSTATIC HYPERTROPHY W/O CC                           MEDICAL           Paid Per Diem          N/A       N/A
  350       12   350-INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM                  DRG               Paid DRG            0.7308       3.1
  351       12   351-MALE STERILIZATION                                            MEDICAL           Paid Per Diem          N/A       N/A
  352       12   352-OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES                      MEDICAL           Paid Per Diem          N/A       N/A
  353       13   353-PELVIC EVISCERATION,RAD HYSTERECTOMY & RAD VULVECTOMY         DRG               Paid DRG            1.8638       5.0
  354       13   354-UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC        DRG               Paid DRG            1.6155       4.3
  355       13   355-UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC      DRG               Paid DRG            1.0063       2.7
  356       13   356-FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES          DRG               Paid DRG            0.8572       1.9
  357       13   357-UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY       DRG               Paid DRG            2.0029       5.6
  358       13   358-UTERINE & ADNEXA PROC FOR CA IN SITU & NONMALIG W CC          DRG               Paid DRG            1.0555       3.0
  359       13   359-UTERINE & ADNEXA PROC FOR CA IN SITU & NONMALIG W/O CC        DRG               Paid DRG            0.7957       2.1
  360       13   360-VAGINA, CERVIX & VULVA PROCEDURES                             DRG               Paid DRG            0.8337       2.4
  361       13   361-LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION                   DRG               Paid DRG            0.8895       1.7
  362       13   362-ENDOSCOPIC TUBAL INTERRUPTION                                 SURGICAL          Paid Per Diem          N/A       N/A
  363       13   363-D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY               SURGICAL          Paid Per Diem          N/A       N/A
  364       13   364-D&C, CONIZATION EXCEPT FOR MALIGNANCY                         DRG               Paid DRG            0.8304       2.6
  365       13   365-OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES              DRG               Paid DRG            1.1536       3.7
  366       13   366-MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM, W CC                  MEDICAL           Paid Per Diem          N/A       N/A
  367       13   367-MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM, W/O CC                MEDICAL           Paid Per Diem          N/A       N/A
  368       13   368-INFECTIONS, FEMALE REPRODUCTIVE SYSTEM                        DRG               Paid DRG            0.7121       2.9
  369       13   369-MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS        DRG               Paid DRG            0.6379       2.1
  370       14   370-CESAREAN SECTION W CC                                         DRG               Paid DRG            0.9358       3.4
  371       14   371-CESAREAN SECTION W/O CC                                       DRG               Paid DRG            0.7799       2.8
  372       14   372-VAGINAL DELIVERY W COMPLICATING DIAGNOSES                     DRG               Paid DRG            0.6096       2.1
  373       14   373-VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES                   DRG               Paid DRG            0.4917       1.6
  374       14   374-VAGINAL DELIVERY W STERILIZATION &/OR D&C                     DRG               Paid DRG            0.7031       2.0
  375       14   375-VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C           DRG               Paid DRG            0.5699       1.9
  376       14   376-POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE       DRG               Paid DRG            0.6051       2.6
  377       14   377-POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE         DRG               Paid DRG            1.1654       3.2
  378       14   378-ECTOPIC PREGNANCY                                             DRG               Paid DRG            0.8395       1.9
  379       14   379-THREATENED ABORTION                                           DRG               Paid DRG            0.7217       3.5
  380       14   380-ABORTION W/O D&C                                              DRG               Paid DRG            0.5284       1.6
  381       14   381-ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY           DRG               Paid DRG            0.7076       2.0
  382       14   382-FALSE LABOR                                                   MEDICAL           Paid Per Diem          N/A       N/A
  392       16   392-SPLENECTOMY AGE >17                                           DRG               Paid DRG            1.7689       4.1
  393       16   393-SPLENECTOMY AGE <18                                           DRG               Paid DRG            1.6849       3.5
  394       16   394-OTHER O.R. PROCS OF THE BLOOD AND BLOOD FORMING ORGANS        DRG               Paid DRG            1.6092       3.6




5/16/2012                                                        Page 6 of 12                                     Tentative and Preliminary
                                                        Washington State Medicaid
                                                        Inpatient System Rebasing
                                                          Payment Type by DRG


                                                                                                                                  Average
                                               Version 23.0                                              Payment        Relative Length of
 DRG    MDC                                 DRG and Description                     Type of Service      Method         Weight     Stay

  395       16   395-RED BLOOD CELL DISORDERS AGE >17                               DRG               Paid DRG            1.1069        3.8
  397       16   397-OTHER COAGULATION DISORDERS                                    DRG               Paid DRG            1.1362        2.9
  398       16   398-RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC                  DRG               Paid DRG            1.4872        4.3
  399       16   399-RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC                DRG               Paid DRG            0.8968        3.0
  401       17   401-LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC           SURGICAL          Paid Per Diem          N/A       N/A
  402       17   402-LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC         SURGICAL          Paid Per Diem          N/A       N/A
  403       17   403-LYMPHOMA & NON-ACUTE LEUKEMIA W CC                             DRG               Paid DRG            2.0036        6.3
  404       17   404-LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC                           MEDICAL           Paid Per Diem          N/A       N/A
  406       17   406-MYELOPRO DISORD OR POOR DIFF NEOPL W MAJ O.R. PROC W CC        SURGICAL          Paid Per Diem          N/A       N/A
  407       17   407-MYELOPRO DISORD OR POOR DIFF NEOP W MAJ O.R. PROC W/O CC       SURGICAL          Paid Per Diem          N/A       N/A
  408       17   408-MYELOPROLIF DISORD OR POOR DIFF NEOPL W OTHER O.R. PROC        SURGICAL          Paid Per Diem          N/A       N/A
  409       17   409-RADIOTHERAPY                                                   MEDICAL           Paid Per Diem          N/A       N/A
  410       17   410-CHEMOTHERAPY                                                   DRG               Paid DRG            1.1740        3.2
  413       17   413-OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC           MEDICAL           Paid Per Diem          N/A       N/A
  414       17   414-OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC         MEDICAL           Paid Per Diem          N/A       N/A
  415       18   415-O.R. PROCEDURE FOR INFECTIOUS & PARASITIC DISEASES             DRG               Paid DRG            1.9396        6.7
  416       18   416-SEPTICEMIA AGE >17                                             DRG               Paid DRG            1.1708        4.5
  417       18   417-SEPTICEMIA AGE <18                                             DRG               Paid DRG            1.2553        4.7
  418       18   418-POSTOPERATIVE & POST-TRAUMATIC INFECTIONS                      DRG               Paid DRG            0.8526        3.6
  419       18   419-FEVER OF UNKNOWN ORIGIN AGE >17 W CC                           DRG               Paid DRG            0.8528        3.1
  420       18   420-FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC                         DRG               Paid DRG            0.5896        2.3
  421       18   421-VIRAL ILLNESS AGE >17                                          DRG               Paid DRG            0.6213        2.4
  422       18   422-VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE <18                DRG               Paid DRG            0.5624        2.2
  423       18   423-OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES                DRG               Paid DRG            1.4532        4.7
  424       19   424-O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS         PSYCH             Paid Per Diem          N/A       N/A
  425       19   425-ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION           PSYCH             Paid Per Diem          N/A       N/A
  426       19   426-DEPRESSIVE NEUROSES                                            PSYCH             Paid Per Diem          N/A       N/A
  427       19   427-NEUROSES EXCEPT DEPRESSIVE                                     PSYCH             Paid Per Diem          N/A       N/A
  428       19   428-DISORDERS OF PERSONALITY & IMPULSE CONTROL                     PSYCH             Paid Per Diem          N/A       N/A
  429       19   429-ORGANIC DISTURBANCES & MENTAL RETARDATION                      PSYCH             Paid Per Diem          N/A       N/A
  430       19   430-PSYCHOSES                                                      PSYCH             Paid Per Diem          N/A       N/A
  431       19   431-CHILDHOOD MENTAL DISORDERS                                     PSYCH             Paid Per Diem          N/A       N/A
  432       19   432-OTHER MENTAL DISORDER DIAGNOSES                                PSYCH             Paid Per Diem          N/A       N/A
  439       21   439-SKIN GRAFTS FOR INJURIES                                       SURGICAL          Paid Per Diem          N/A       N/A
  440       21   440-WOUND DEBRIDEMENTS FOR INJURIES EXCEPT OPEN WOUND              SURGICAL          Paid Per Diem          N/A       N/A
  441       21   441-HAND PROCEDURES FOR INJURIES                                   SURGICAL          Paid Per Diem          N/A       N/A
  442       21   442-OTHER O.R. PROCEDURES FOR INJURIES W CC                        DRG               Paid DRG            2.0575        5.7
  443       21   443-OTHER O.R. PROCEDURES FOR INJURIES W/O CC                      DRG               Paid DRG            1.1344        2.9
  444       21   444-INJURIES TO UNSPEC OR MULTIPLE SITES, AGE >17 W CC             MEDICAL           Paid Per Diem          N/A       N/A
  445       21   445-INJURIES TO UNSPEC OR MULTIPLE SITES, AGE >17 W/O CC           MEDICAL           Paid Per Diem          N/A       N/A
  446       21   446-INJURIES TO UNSPECIFIED OR MULTIPLE SITES, AGE <18             DRG               Paid DRG            0.6687        1.9
  447       21   447-ALLERGIC REACTIONS AGE >17                                     DRG               Paid DRG            0.6500        2.1
  448       21   448-ALLERGIC REACTIONS AGE <18                                     MEDICAL           Paid Per Diem          N/A       N/A
  449       21   449-POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC                DRG               Paid DRG            0.6651        2.5
  450       21   450-POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/O CC              DRG               Paid DRG            0.5101        1.8
  451       21   451-POISONING & TOXIC EFFECTS OF DRUGS AGE <18                     DRG               Paid DRG            0.5549        1.8
  452       21   452-COMPLICATIONS OF TREATMENT W CC                                DRG               Paid DRG            0.8395        2.8
  453       21   453-COMPLICATIONS OF TREATMENT W/O CC                              DRG               Paid DRG            0.7437        2.7
  454       21   454-OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSIS W CC          DRG               Paid DRG            1.2400        3.8
  455       21   455-OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSIS W/O CC        MEDICAL           Paid Per Diem          N/A       N/A
  461       23   461-O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES       SURGICAL          Paid Per Diem          N/A       N/A
  462       23   462-REHABILITATION                                                 REHAB             Paid Per Diem          N/A       N/A
  463       23   463-SIGNS & SYMPTOMS W CC                                          DRG               Paid DRG            0.9684        3.3
  464       23   464-SIGNS & SYMPTOMS W/O CC                                        MEDICAL           Paid Per Diem          N/A       N/A
  465       23   465-AFTERCARE W HISTORY OF MALIGNANCY AS 2ND DIAGNOSIS             MEDICAL           Paid Per Diem          N/A       N/A
  466       23   466-AFTERCARE W/O HISTORY OF MALIGNANCY AS 2ND DIAGNOSIS           MEDICAL           Paid Per Diem          N/A       N/A
  467       23   467-OTHER FACTORS INFLUENCING HEALTH STATUS                        MEDICAL           Paid Per Diem          N/A       N/A
  468       98   468-EXTEN O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS          DRG               Paid DRG            4.2151       11.0
  469       99   469-PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS             UNGROUPED                                N/A       N/A
  470       99   470-UNGROUPABLE                                                    UNGROUPED                                N/A       N/A
  471        8   471-BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREM        DRG               Paid DRG            3.4969        4.8




5/16/2012                                                         Page 7 of 12                                     Tentative and Preliminary
                                                       Washington State Medicaid
                                                       Inpatient System Rebasing
                                                         Payment Type by DRG


                                                                                                                                 Average
                                              Version 23.0                                              Payment        Relative Length of
 DRG    MDC                                DRG and Description                     Type of Service      Method         Weight     Stay

  476       98   476-PROSTATIC O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS          SURGICAL          Paid Per Diem          N/A       N/A
  477       98   477-NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS      DRG               Paid DRG            2.2416        7.1
  478        5   478-OTHER VASCULAR PROCEDURES W CC                                DRG               Paid DRG            2.5090        4.1
  479        5   479-OTHER VASCULAR PROCEDURES W/O CC                              DRG               Paid DRG            1.7701        2.0
  480        0   480-LIVER TRANSPLANT                                              TRANSPLANT        RCC                    N/A       N/A
  482        0   482-TRACHEOSTOMY WITH MOUTH, LARYNX OR PHARYNX DISORDER           DRG               Paid DRG            5.4237       13.4
  491        8   491-MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY       DRG               Paid DRG            2.0200        2.7
  493        7   493-LAPAROSCOPIC CHOLECYSTECTOMY W/O CDE W CC                     DRG               Paid DRG            1.4347        3.7
  494        7   494-LAPAROSCOPIC CHOLECYSTECTOMY W/O CDE W/O CC                   DRG               Paid DRG            1.0246        2.1
  530        1   530-CRANIOTOMY W MAJOR CC                                         DRG               Paid DRG            9.5100       18.2
  531        1   531-NERVOUS SYSTEM PROCEDURES EXCEPT CRANIOTOMY W MAJOR CC        DRG               Paid DRG            5.3315       13.3
  532        1   532-TIA, PRECERBRAL OCCLUSIONS, SEIZ & HEADACHE W MCC             DRG               Paid DRG            1.6397        4.7
  533        1   533-OTH NERV SYS DISORD EXC TIA, SEIZ & HEADACHE W MAJOR CC       DRG               Paid DRG            2.5601        7.9
  534        2   534-EYE PROCEDURES W MAJOR CC                                     SURGICAL          Paid Per Diem          N/A       N/A
  535        2   535-EYE DISORDERS W MAJOR CC                                      MEDICAL           Paid Per Diem          N/A       N/A
  536        3   536-ENT & MOUTH PROCS EXCEPT MAJOR HEAD & NECK W MAJOR CC         SURGICAL          Paid Per Diem          N/A       N/A
  538        4   538-MAJOR CHEST PROCEDURES W MAJOR CC                             DRG               Paid DRG            5.4210       13.2
  539        4   539-RESPIRATORY PROCEDURES EXCEPT MAJOR CHEST W MAJOR CC          DRG               Paid DRG            4.4166       11.3
  540        4   540-RESPIRATORY INFECTIONS & INFLAMMATIONS W MAJOR CC             DRG               Paid DRG            2.2704        7.8
  541        4   541-RESP DISORD EXC INFECTIONS,BRONCHITIS,ASTHMA W MAJOR CC       DRG               Paid DRG            1.6889        5.7
  543        5   543-CIRC DISORD EXC AMI,ENDOCARDITIS,CHF & ARRHYT W MAJOR CC      DRG               Paid DRG            2.1387        6.1
  544        5   544-CHF & CARDIAC ARRHYTHMIA W MAJOR CC                           DRG               Paid DRG            2.1094        6.2
  545        5   545-CARDIAC VALVE OR CARDIAC DEFIB IMPLANT PROCEDURE W MAJOR CC   DRG               Paid DRG           11.5664       15.0
  546        5   546-CORONARY BYPASS W MAJOR CC                                    DRG               Paid DRG            7.8141       12.3
  547        5   547-OTHER CARDIOTHORACIC PROCEDURE W MAJOR CC                     DRG               Paid DRG           12.7537       15.8
  548        5   548-CARDIAC PACEMAKER IMPLANT OR REVISION W MAJOR CC              SURGICAL          Paid Per Diem          N/A       N/A
  549        5   549-MAJOR CARDIOVASCULAR PROCEDURES W MAJOR CC                    DRG               Paid DRG            8.8053       14.2
  550        5   550-OTHER VASCULAR PROCEDURES W MAJOR CC                          DRG               Paid DRG            4.0789        7.5
  551        6   551-ESOPHAGITIS,GASTROENT & UNCOMPLICATED ULCERS W MAJOR CC       DRG               Paid DRG            1.6084        5.5
  552        6   552-DIGEST SYS DISORD EXC ESOP,GAST & UNCOMP ULCERS W MAJ CC      DRG               Paid DRG            2.1908        7.1
  553        6   553-DIGEST SYS PROCS EXC HERN,M STOM OR BWL PROCS W MAJOR CC      DRG               Paid DRG            3.8987       10.3
  554        6   554-HERNIA PROCEDURES W MAJOR CC                                  SURGICAL          Paid Per Diem          N/A       N/A
  555        7   555-PANCREA,LIV & OTH BIL TRT PROC EXC LIV TRPLNT W MAJOR CC      DRG               Paid DRG            7.5284       16.5
  556        7   556-CHOLECYSTECTOMY & OTHER HEPATOBILIARY PROCS W MAJOR CC        DRG               Paid DRG            4.0758       10.8
  557        7   557-HEPATOBILIARY & PANCREAS DISORDERS W MAJOR CC                 DRG               Paid DRG            2.5391        7.9
  558        8   558-MAJ MUSCULOSKEL PROCS EXC BILAT OR MULT MAJ JNT W MAJ CC      DRG               Paid DRG            5.4753       12.2
  559        8   559-NON-MAJOR MUSCULOSKELETAL PROCEDURES W MAJOR CC               DRG               Paid DRG            3.5892        8.8
  560        8   560-MUSCULO DISORD EXC OSTEO,SEP ARTH & CONN TISS W MAJOR CC      MEDICAL           Paid Per Diem          N/A       N/A
  561        8   561-OSTEOMYEL,SEPTIC ARTHRITIS & CONN TISS DISORD W MAJOR CC      MEDICAL           Paid Per Diem          N/A       N/A
  562        8   562-MAJOR SKIN & BREAST DISORDERS W MAJOR CC                      MEDICAL           Paid Per Diem          N/A       N/A
  563        9   563-OTHER SKIN DISORDERS W MAJOR CC                               DRG               Paid DRG            1.6260        6.4
  564        9   564-SKIN & BREAST PROCEDURES W MAJOR CC                           DRG               Paid DRG            3.3525       12.4
  565       10   565-ENDOC,NUTRIT & METAB PROC EXC LOW LIMB W AMPUT W MAJ CC       SURGICAL          Paid Per Diem          N/A       N/A
  566       10   566-ENDOC,NUTRIT & METAB DISOR EXC EAT DISORD OR CF W MAJ CC      DRG               Paid DRG            1.4927        5.1
  567       11   567-KID & URIN TRACT PROCS EXC KIDNEY TRANSPLANT W MAJOR CC       DRG               Paid DRG            3.7865        9.9
  568       11   568-RENAL FAILURE W MAJOR CC                                      DRG               Paid DRG            2.3534        7.3
  569       11   569-KID & URIN TRACT DISORD EXC RENAL FAILURE W MAJOR CC          DRG               Paid DRG            1.3367        4.8
  570       12   570-MALE REPRODUCTIVE DISORDERS W MAJOR CC                        MEDICAL           Paid Per Diem          N/A       N/A
  571       12   571-MALE REPRODUCTIVE PROCEDURES W MAJOR CC                       SURGICAL          Paid Per Diem          N/A       N/A
  572       13   572-FEMALE REPRODUCTIVE DISORDERS W MAJOR CC                      MEDICAL           Paid Per Diem          N/A       N/A
  573       13   573-NON-RADICAL FEMALE REPRODUCTIVE PROCEDURES W MAJOR CC         DRG               Paid DRG            2.0131        5.4
  574       16   574-BLOOD,BLOOD FORM ORGANS & IMMUNOLOG DISORD W MAJOR CC         DRG               Paid DRG            2.5361        7.1
  575       16   575-BLOOD,BLOOD FORM ORGANS & IMMUNOLOG PROCS W MAJOR CC          SURGICAL          Paid Per Diem          N/A       N/A
  576       17   576-ACUTE LEUKEMIA W MAJOR CC                                     DRG               Paid DRG            8.6252       21.3
  577       17   577-MYELOPROL DISORD & POORLY DIFFER NEOPLASMS W MAJOR CC         DRG               Paid DRG            4.1077       11.4
  578       17   578-LYMPHOMA & NON-ACUTE LEUKEMIA W MAJOR CC                      MEDICAL           Paid Per Diem          N/A       N/A
  579       17   579-PROCS FOR LYMPH,LEUKEMIA,MYELOPROLIF DISORD W MAJOR CC        SURGICAL          Paid Per Diem          N/A       N/A
  580       18   580-SYST INFECT & PARASITIC DISORD EXC SEPTICEMIA W MAJOR CC      DRG               Paid DRG            2.1786        6.7
  581       18   581-SYSTEMIC INFECT & PARASITIC DISORD PROCEDURES W MAJOR CC      DRG               Paid DRG            6.3617       15.9
  582       21   582-INJURIES EXCEPT MULTIPLE TRAUMA W MAJOR CC                    DRG               Paid DRG            1.6527        4.5
  583       21   583-PROCS FOR INJURIES EXCEPT MULTIPLE TRAUMA W MAJOR CC          DRG               Paid DRG            3.8603       10.4




5/16/2012                                                        Page 8 of 12                                     Tentative and Preliminary
                                                        Washington State Medicaid
                                                        Inpatient System Rebasing
                                                          Payment Type by DRG


                                                                                                                                  Average
                                               Version 23.0                                              Payment        Relative Length of
 DRG    MDC                                 DRG and Description                     Type of Service      Method         Weight     Stay

  584       18   584-SEPTICEMIA W MAJOR CC                                          DRG               Paid DRG            3.1115        8.2
  585        6   585-MAJ STOMACH,ESOP,DUOD,SMALL & LRG BOWEL PROC W MAJOR CC        DRG               Paid DRG            6.1618       15.7
  586        3   586-ENT & MOUTH DISORDERS, AGE > 17 WITH MAJOR CC                  MEDICAL           Paid Per Diem          N/A       N/A
  587        3   587-ENT & MOUTH DISORDERS, AGE < 18 WITH MAJOR CC                  MEDICAL           Paid Per Diem          N/A       N/A
  588        4   588-BRONCHITIS AND ASTHMA AGE> 17 W MAJOR CC                       DRG               Paid DRG            1.0928        4.0
  589        4   589-BRONCHITIS AND ASTHMA AGE< 17 W MAJOR CC                       DRG               Paid DRG            0.9470        3.3
  602       15   602-NEONATE, BIRTHWT <750G, DISCHARGED ALIVE                       DRG               Paid DRG           27.2365       87.3
  603       15   603-NEONATE, BIRTHWT <750G,DIED                                    NEONATAL          Paid Per Diem          N/A       N/A
  604       15   604-NEONATE, BIRTHWT 750-999G, DISCHARGED ALIVE                    DRG               Paid DRG           21.0336       71.7
  605       15   605-NEONATE, BIRTHWT 750-999, DIED                                 NEONATAL          Paid Per Diem          N/A       N/A
  606       15   606-NEONATE, BWT 1000-1499G, W SIG OR PROC, DISCH ALIVE            NEONATAL          Paid Per Diem          N/A       N/A
  607       15   607-NEONATE, BWT 1000-1499G, W/O SIGNIF OR PROC, DISCH ALIVE       DRG               Paid DRG           10.2224       41.0
  608       15   608-NEONATE, BIRTHWT 1000-1499G, DIED                              NEONATAL          Paid Per Diem          N/A       N/A
  609       15   609-NEONATE, BWT 1500-1999G, W SIG OR PROC, W MULT MAJ PROB        NEONATAL          Paid Per Diem          N/A       N/A
  610       15   610-NEONATE, BWT 1500-1999G, W SIG OR PROC, W/O MUL MAJ PROB       NEONATAL          Paid Per Diem          N/A       N/A
  611       15   611-NEONATE, BWT 1500-1999G, W/O SIG OR PROC, W MUL MAJ PROB       DRG               Paid DRG            7.9538       30.6
  612       15   612-NEONATE, BWT 1500-1999G, W/O SIG OR PROC, W MAJOR PROB         DRG               Paid DRG            4.2051       20.5
  613       15   613-NEONATE, BWT 1500-1999G, W/O SIG OR PROC, W MINOR PROB         DRG               Paid DRG            4.1052       21.0
  614       15   614-NEONATE, BWT 1500-1999G, W/O SIG OR PROC, W OTHER PROB         DRG               Paid DRG            2.1849       11.5
  615       15   615-NEONATE, BWT 2000-2499G, W SIG OR PROC, W MUL MAJOR PROB       NEONATAL          Paid Per Diem          N/A       N/A
  616       15   616-NEONATE, BWT 2000-2499G, W SIG OR PROC, W/O MUL MAJ PROB       NEONATAL          Paid Per Diem          N/A       N/A
  617       15   617-NEONATE, BWT 2000-2499G, W/O SIG OR PROC, W MUL MAJ PROB       DRG               Paid DRG            4.3664       18.7
  618       15   618-NEONATE, BWT 2000-2499G, W/O SIG OR PROC, W MAJOR PROB         DRG               Paid DRG            2.4423       11.9
  619       15   619-NEONATE, BWT 2000-2499G, W/O SIG OR PROC, W MINOR PROB         DRG               Paid DRG            2.0236       11.3
  620       15   620-NEONATE,BWT 2000-2499G,W/O SIG OR PROC, W NORM NEWB DIAG       DRG               Paid DRG            0.3475        2.8
  621       15   621-NEONATE, BWT 2000-2499G, W/O SIG OR PROC, W OTHER PROB         DRG               Paid DRG            1.5484        8.7
  622       15   622-NEONATE, BWT >2499G, W SIG OR PROC, W MULT MAJOR PROB          DRG               Paid DRG           15.7969       34.1
  623       15   623-NEONATE, BWT >2499G, W SIG OR PROC, W/O MULT MAJOR PROB        NEONATAL          Paid Per Diem          N/A       N/A
  624       15   624-NEONATE, BIRTHWT >2499G, W MINOR ABDOM PROC                    NEONATAL          Paid Per Diem          N/A       N/A
  626       15   626-NEONATE, BWT >2499G, W/O SIG OR PROC, W MULT MAJOR PROB        DRG               Paid DRG            3.0870       11.5
  627       15   627-NEONATE, BWT >2499G, W/O SIGNIF OR PROC, W MAJOR PROB          DRG               Paid DRG            0.8953        4.9
  628       15   628-NEONATE, BWT >2499G, W/O SIGNIF OR PROC, W MINOR PROB          DRG               Paid DRG            0.5767        3.3
  629       15   629-NEONATE, BWT >2499G, W/O SIGN OR PROC, W NORM NEWB DIAG        DRG               Paid DRG            0.1721        1.7
  630       15   630-NEONATE, BWT >2499G, W/O SIG OR PROC, W OTHER PROB             DRG               Paid DRG            0.6385        4.2
  631        4   631-BPD AND OTHER CHRON RESP DISEAS ARISING PERINATAL PERIOD       DRG               Paid DRG            1.4779        5.4
  633       23   633-MULT,OTHER AND UNSPEC CONGENITAL ANOMALIES W CC                MEDICAL           Paid Per Diem          N/A       N/A
  634       23   634-MULT,OTHER AND UNSPEC CONGENITAL ANOMALIES W/O CC              MEDICAL           Paid Per Diem          N/A       N/A
  635       15   635-NEONATAL AFTERCARE FOR WEIGHT GAIN                             NEONATAL          Paid Per Diem          N/A       N/A
  636       23   636-INFANT AFTERCARE FOR WEIGHT GAIN, AGE>28 DAYS & <1 YEAR        SURGICAL          Paid Per Diem          N/A       N/A
  637       15   637-NEONATE, DIED W/IN ONE DAY OF BIRTH, BORN HERE                 DRG               Paid DRG            0.3786        1.0
  638       15   638-NEONATE, DIED W/IN ONE DAY OF BIRTH, NOT BORN HERE             NEONATAL          Paid Per Diem          N/A       N/A
  639       15   639-NEONATE, TRANSFERRED <5 DAYS OF BIRTH, BORN HERE               DRG               Paid DRG            0.3524        1.4
  640       15   640-NEONATE, TRANSFERRED <5 DAYS OF BIRTH, NOT BORN HERr           NEONATAL          Paid Per Diem          N/A       N/A
  641       15   641-EXTRACORPOREAL MEMBRANE OXYGENATION, BWT >2499 GRAMS           NEONATAL          Paid Per Diem          N/A       N/A
  650       14   650-HIGH RISK CESAREAN SECTION W CC                                DRG               Paid DRG            1.3110        5.1
  651       14   651-HIGH RISK CESAREAN SECTION W/O CC                              DRG               Paid DRG            1.0361        4.1
  652       14   652-HIGH RISK VAGINAL DELIVERY W STERILIZATION AND/OR D7c          DRG               Paid DRG            0.9057        2.8
  700       24   700-TRACHEOSTOMY FOR HIV INFECTION                                 SURGICAL          Paid Per Diem          N/A       N/A
  701       24   701-HIV W O.R. PROCEDURE & VENTILATION OR NUTRITION SUPPORT        SURGICAL          Paid Per Diem          N/A       N/A
  702       24   702-HIV W O.R. PROCEDURE W MULTIPLE MAJOR RELATED INFECtions       SURGICAL          Paid Per Diem          N/A       N/A
  703       24   703-HIV W O.R. PROCEDURE W MAJOR RELATED DIAGNOSIS                 SURGICAL          Paid Per Diem          N/A       N/A
  704       24   704-HIV W O.R. PROCEDURE W/O MAJOR RELATED DIAGNOSIS               SURGICAL          Paid Per Diem          N/A       N/A
  705       24   705-HIV W MULTIPLE MAJOR RELATED INFECTIONS W TB                   MEDICAL           Paid Per Diem          N/A       N/A
  706       24   706-HIV W MULTIPLE MAJOR RELATED INFECTIONS W/O TB                 MEDICAL           Paid Per Diem          N/A       N/A
  707       24   707-HIV W VENTILATOR OR NUTRITIONAL SUPPORT                        MEDICAL           Paid Per Diem          N/A       N/A
  708       24   708-HIV W MAJOR RELATED DIAGNOSIS, DISCHARGE AMA                   MEDICAL           Paid Per Diem          N/A       N/A
  709       24   709-HIV W MAJOR RELATED DIAG W MULT MAJOR OR SIGN DIAG W TB        MEDICAL           Paid Per Diem          N/A       N/A
  710       24   710-HIV W MAJOR RELATED DIAG W MULT MAJ OR SIGN DIAG W/O TB        DRG               Paid DRG            1.9415        7.0
  711       24   711-HIV W MAJOR RELAT DIAG W/O MULT MAJ OR SIGNIF DIAG W TB        MEDICAL           Paid Per Diem          N/A       N/A
  712       24   712-HIV W MAJ RELAT DIAG W/O MULT MAJ OR SIGNIF DIAG W/O TB        DRG               Paid DRG            1.3307        6.5
  713       24   713-HIV W SIGNIFICANT RELATED DIAGNOSIS, DISCHARGED AMA            MEDICAL           Paid Per Diem          N/A       N/A




5/16/2012                                                         Page 9 of 12                                     Tentative and Preliminary
                                                        Washington State Medicaid
                                                        Inpatient System Rebasing
                                                          Payment Type by DRG


                                                                                                                                  Average
                                               Version 23.0                                              Payment        Relative Length of
 DRG    MDC                                 DRG and Description                     Type of Service      Method         Weight     Stay

  714       24   714-HIV W SIGNIFICANT RELATED DIAGNOSIS                            DRG               Paid DRG            1.2178        4.6
  715       24   715-HIV W OTHER RELATED DIAGNOSES                                  DRG               Paid DRG            0.8019        3.3
  716       24   716-HIV W/O OTHER RELATED DIAGNOSES                                MEDICAL           Paid Per Diem          N/A       N/A
  730       25   730-CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA                     SURGICAL          Paid Per Diem          N/A       N/A
  731       25   731-SPINE, HIP, FEMUR OR LIMB PROC FOR MULT SIGNIF TRAUMA          DRG               Paid DRG            6.8384       13.0
  732       25   732-OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA          DRG               Paid DRG            4.7559        9.1
  733       25   733-HEAD, CHEST & LOWER LIMB DIAGNOSES OF MULT SIGNIF TRAUMA       DRG               Paid DRG            2.0843        4.5
  734       25   734-OTHER DIAGNOSES OF MULTIPLE SIGNIFICANT TRAUMA                 MEDICAL           Paid Per Diem          N/A       N/A
  737        1   737-VENTRICULAR SHUNT REVISION                                     DRG               Paid DRG            1.5937        2.7
  738        1   738-CRANIOTOMY, AGE <18 W CC                                       DRG               Paid DRG            4.4611        8.1
  739        1   739-CRANIOTOMY, AGE <18 W/O CC                                     DRG               Paid DRG            3.1156        4.2
  740        4   740-CYSTIC FIBROSIS                                                DRG               Paid DRG            3.1449       10.0
  743       20   743-OPIOID ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE         SUB_AB            Paid Per Diem          N/A       N/A
  744       20   744-OPIOID ABUSE OR DEPENDENCE W CC                                SUB_AB            Paid Per Diem          N/A       N/A
  745       20   745-OPIOID ABUSE OR DEPENDENCE W/O CC                              SUB_AB            Paid Per Diem          N/A       N/A
  746       20   746-COCAINE OR OTHER DRUG ABUSE OR DEPENDENCE LEFT AMA             SUB_AB            Paid Per Diem          N/A       N/A
  747       20   747-COCAINE OR OTHER DRUG ABUSE OR DEPENDENCE W CC                 SUB_AB            Paid Per Diem          N/A       N/A
  748       20   748-COCAINE OR OTHER DRUG ABUSE OR DEPENDENCE W/O CC               SUB_AB            Paid Per Diem          N/A       N/A
  749       20   749-ALCOHOL ABUSE OR DEPENDENCE LEFT AMA                           SUB_AB            Paid Per Diem          N/A       N/A
  750       20   750-ALCOHOL ABUSE OR DEPENDENCE W CC                               SUB_AB            Paid Per Diem          N/A       N/A
  751       20   751-ALCOHOL ABUSE OR DEPENDENCE W/O CC                             SUB_AB            Paid Per Diem          N/A       N/A
  752       21   752-LEAD POISONING                                                 MEDICAL           Paid Per Diem          N/A       N/A
  753       10   753-COMPULSIVE NUTRITION DISORDER REHABILITATION                   MEDICAL           Paid Per Diem          N/A       N/A
  754       23   754-TERTIARY AFTERCARE, AGE => 1 YEAR                              MEDICAL           Paid Per Diem          N/A       N/A
  755        8   755-SPINAL FUSION W CC                                             DRG               Paid DRG            5.1164        5.7
  756        8   756-SPINAL FUSION W/O CC                                           DRG               Paid DRG            3.6290        3.8
  757        8   757-BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W CC               DRG               Paid DRG            1.3459        3.2
  758        8   758-BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC             DRG               Paid DRG            0.9675        2.0
  759        3   759-MULTIPLE CHANNEL COCHLEAR IMPLANTS                             SURGICAL          Paid Per Diem          N/A       N/A
  760       16   760-HEMOPHILIA FACTORS VIII AND IX                                 MEDICAL           Paid Per Diem          N/A       N/A
  761        1   761-TRAUMATIC STUPOR & COMA, COMA >1 HR                            DRG               Paid DRG            1.3259        2.6
  762        1   762-CONCUSSION,INTRACRAN INJ W COMA <1 HR OR NO COMA AGE <18       DRG               Paid DRG            0.7570        1.7
  763        1   763-TRAUMATIC STUPOR & COMA, COMA <1 HR AGE <18                    DRG               Paid DRG            0.8122        2.1
  764        1   764-CONCUSS,INTRACRAN INJ W COMA<1 HR OR NO COMA AGE>17 W CC       MEDICAL           Paid Per Diem          N/A       N/A
  765        1   765-CONCUSS,INTRACRAN INJ W COMA<1 HR /NO COMA AGE>17 W/O CC       MEDICAL           Paid Per Diem          N/A       N/A
  766        1   766-TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W CC               DRG               Paid DRG            1.4946        4.9
  767        1   767-TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W/O CC             DRG               Paid DRG            0.9014        2.4
  768        1   768-SEIZURE & HEADACHE AGE <18 W CC                                DRG               Paid DRG            0.9873        2.5
  769        1   769-SEIZURE & HEADACHE AGE <18 W/O CC                              DRG               Paid DRG            0.7887        2.1
  770        4   770-RESPIRATORY INFECTIONS & INFLAMMATIONS AGE <18 W CC            MEDICAL           Paid Per Diem          N/A       N/A
  771        4   771-RESPIRATORY INFECTIONS & INFLAMMATIONS AGE <18 W/O CC          MEDICAL           Paid Per Diem          N/A       N/A
  772        4   772-SIMPLE PNEUMONIA & PLEURISY AGE <18 W CC                       DRG               Paid DRG            0.7174        2.9
  773        4   773-SIMPLE PNEUMONIA & PLEURISY AGE <18 W/O CC                     DRG               Paid DRG            0.6206        2.8
  774        4   774-BRONCHITIS & ASTHMA AGE <18 W CC                               DRG               Paid DRG            0.8684        3.3
  775        4   775-BRONCHITIS & ASTHMA AGE <18 W/O CC                             DRG               Paid DRG            0.5911        2.4
  776        6   776-ESOPHAGITIS,GASTROENT & MISC DIGEST DISORD AGE <18 W CC        DRG               Paid DRG            1.0085        3.6
  777        6   777-ESOPHAGIT,GASTROENT & MISC DIGEST DISORD AGE <18 W/O CC        DRG               Paid DRG            0.7604        2.8
  778        6   778-OTHER DIGESTIVE SYSTEM DIAGNOSES AGE <18 W CC                  MEDICAL           Paid Per Diem          N/A       N/A
  779       17   779-OTHER DIGESTIVE SYSTEM DIAGNOSES AGE <18 W/O CC                DRG               Paid DRG            0.7007        2.1
  780       17   780-ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE <18 W CC           DRG               Paid DRG            6.1887       12.7
  781       17   781-ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE <18 W/O CC         MEDICAL           Paid Per Diem          N/A       N/A
  782       17   782-ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE >17 W CC           MEDICAL           Paid Per Diem          N/A       N/A
  783       17   783-ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE >17 W/O CC         MEDICAL           Paid Per Diem          N/A       N/A
  784       16   784-ACQUIRED HEMOLYTIC ANEMIA OR SICKLE CELL CRISIS AGE <18        DRG               Paid DRG            1.7271        4.4
  785       16   785-OTHER RED BLOOD CELL DISORDERS AGE <18                         DRG               Paid DRG            1.1119        3.0
  786        3   786-MAJOR HEAD & NECK PROCEDURES FOR MALIGNANCY                    DRG               Paid DRG            2.0700        5.1
  787        7   787-LAPAROSCOPIC CHOLECYSTECTOMY W CDE                             SURGICAL          Paid Per Diem          N/A       N/A
  789        8   789-MAJOR JOINT & LIMB REATTACH PROC LOW EXT, EXC HIP,FOR COMP     DRG               Paid DRG            2.6085        3.5
  790        8   790-WND DEBRID & SKN GRFT FOR OPEN WOUND,MS CONN TIS,EXC HND       SURGICAL          Paid Per Diem          N/A       N/A
  791       21   791-WOUND DEBRIDEMENTS FOR OPEN WOUND INJURIES                     DRG               Paid DRG            1.1404        4.5
  792       25   792-CRANIOTOMY FOR MULT SIG TRAUMA W NON-TRAUMATIC MAJOR CC        DRG               Paid DRG           12.0544       22.3




5/16/2012                                                         Page 10 of 12                                    Tentative and Preliminary
                                                       Washington State Medicaid
                                                       Inpatient System Rebasing
                                                         Payment Type by DRG


                                                                                                                                    Average
                                              Version 23.0                                                 Payment        Relative Length of
 DRG    MDC                                DRG and Description                        Type of Service      Method         Weight     Stay

  793       25   793-PROC FOR MUL SIG TRAUMA EXC CRANIOT W NON-TRAUM MAJOR CC         DRG               Paid DRG           10.9795       20.6
  794       25   794-DIAG FOR MULTIPLE SIGNIF TRAUMA W NON-TRAUMATIC MAJOR CC         MEDICAL           Paid Per Diem          N/A       N/A
  795        0   795-LUNG TRANSPLANT                                                  TRANSPLANT        RCC                    N/A       N/A
  796        5   796-LOWER EXTREMITY REVASCULARIZATION W CC                           DRG               Paid DRG            2.5495        5.6
  797        5   797-LOWER EXTREMITY REVASCULARIZATION W/O CC                         DRG               Paid DRG            1.7482        2.9
  798        4   798-TUBERCULOSIS WITH OPERATING ROOM PROCEDURE                       SURGICAL          Paid Per Diem          N/A       N/A
  799        4   799-TUBERCULOSIS LEFT AGAINST MEDICAL ADVICE                         MEDICAL           Paid Per Diem          N/A       N/A
  800        4   800-TUBERCULOSIS W CC                                                MEDICAL           Paid Per Diem          N/A       N/A
  801        4   801-TUBERCULOSIS W/O CC                                              MEDICAL           Paid Per Diem          N/A       N/A
  802        4   802-PNEUMOCYSTOSIS                                                   MEDICAL           Paid Per Diem          N/A       N/A
  803        0   803-ALLOGENEIC BONE MARROW TRANSPLANT                                TRANSPLANT        RCC                    N/A       N/A
  804        0   804-AUTOLOGOUS BONE MARROW TRANSPLANT                                TRANSPLANT        RCC                    N/A       N/A
  805        0   805-SIMULTANEOUS KIDNEY AND PANCREAS TRANSPLANT                      TRANSPLANT        RCC                    N/A       N/A
  806        8   806-COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC                   DRG               Paid DRG            7.7084        7.9
  807        8   807-COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC                 DRG               Paid DRG            6.4429        7.0
  808        5   808-PERCUATANEOUS CARDIOVASC PROC W AMI, HF OR SHOCK                 DRG               Paid DRG            2.7631        3.2
  809        5   809-OTHER CARDIOTHORACIC PROCEDURES W PDX CONG ANOMALY               DRG               Paid DRG            5.9824        6.7
  810        1   810-INTRACRANIAL HEMORRHAGE                                          DRG               Paid DRG            1.8271        5.1
  811        5   811-HEART ASSIST SYSTEM IMPLANT                                      SURGICAL          Paid Per Diem          N/A       N/A
  812        5   812-MALFUNCTION, REACTION & COMP OF CARDIAC OR VASC DEV OR PROC      DRG               Paid DRG            1.2095        3.9
  813        6   813-NONBACTERIAL GASTROENTERITIS & ABDOMINAL PAIN AGE >17 W CC       DRG               Paid DRG            0.8021        3.1
  814        6   814-NONBACTERIAL GASTROENTERITIS & ABDOMINAL PAIN AGE >17 W/O CC     DRG               Paid DRG            0.6377        2.5
  815        6   815-NONBACTERIAL GASTROENTERITIS & ABDOMINAL PAIN AGE <18 W CC       DRG               Paid DRG            0.7204        2.4
  816        6   816-NONBACTERIAL GASTROENTERITIS & ABDOMINAL PAIN AGE <8 W/O CC      DRG               Paid DRG            0.4775        2.0
  817        8   817-HIP REPLACEMENT FOR COMPLICATIONS                                DRG               Paid DRG            2.7274        4.4
  818        8   818-HIP REPLACEMENTS EXCEPT FOR COMPLICATIONS                        DRG               Paid DRG            2.5932        4.2
  819       11   819-CREATE, REVISE OR REMOVE RENAL ACCESS DEVICE                     DRG               Paid DRG            1.4282        2.9
  820       11   820-MALFUNCTIONS, REACTIONS & COMP OF GU DEVICE/GRAFT/TRANSPLANT     DRG               Paid DRG            0.9807        3.3
  821       22   821-EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT                          BURN              Paid Per Diem          N/A       N/A
  822       22   822-EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT                        BURN              Paid Per Diem          N/A       N/A
  823       22   823-FULL THICK BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA     BURN              Paid Per Diem          N/A       N/A
  824       22   824-FULL THICK BURN W SKIN GRAFT OR INHAL INJ W/O CC OR SIG TRAUMA   BURN              Paid Per Diem          N/A       N/A
  825       22   825-FULL THICK BURN W/O SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA   BURN              Paid Per Diem          N/A       N/A
  826       22   826-FULL THICK BURN W/O SKIN GRAFT OR INHAL INJ W/O CC OR SIG TR     BURN              Paid Per Diem          N/A       N/A
  827       22   827-NON-EXTENSIVE BURNS W INHAL INJ, CC OR SIGNIFICANT TRAUMA        BURN              Paid Per Diem          N/A       N/A
  828       22   828-NON-EXTENSIVE BURNS W/O INHAL INJ, CC OR SIG. TRAUMA             DRG               Paid DRG            0.4600        2.5
  829        0   829-PANCREAS TRANSPLANT                                              TRANSPLANT        RCC                    N/A       N/A
  832        1   832-TRANSIENT ISCHEMIA                                               DRG               Paid DRG            0.7132        2.0
  833        1   833-INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE                DRG               Paid DRG            9.2773       15.3
  836        1   836-SPINAL PROCEDURES W CC                                           DRG               Paid DRG            3.1649        6.7
  837        1   837-SPINAL PROCEDURES W/O CC                                         DRG               Paid DRG            2.2230        3.7
  838        1   838-EXTRACRANIAL PROCEDURES W CC                                     DRG               Paid DRG            1.7067        3.1
  839        1   839-EXTRACRANIAL PROCEDURES W/O CC                                   DRG               Paid DRG            1.0795        1.6
  849        5   849-CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK              SURGICAL          Paid Per Diem          N/A       N/A
  850        5   850-CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK            SURGICAL          Paid Per Diem          N/A       N/A
  851        5   851-CARDIAC DEFIBRILLATOR W/O CARDIAC CATHETER                       DRG               Paid DRG            8.4675        3.4
  852        5   852-PERCUTANEOUS CARDIOVAS PROC W NON-DRUG ELUTING STENT W O AMI     DRG               Paid DRG            2.1732        1.9
  853        5   853-PERCUTANEOUS CARDIOVAS PROC W DRUG ELUTING STENT W AMI           DRG               Paid DRG            3.1612        2.8
  854        5   854-PERCUTANEOUS CARDIOVAS PROC W DRUG ELUTING STENT W/O AMI         DRG               Paid DRG            2.7815        1.9
  864        8   864-CERVICAL SPINAL FUSION W CC                                      DRG               Paid DRG            2.5619        2.8
  865        8   865-CERVICAL SPINAL FUSION W/O CC                                    DRG               Paid DRG            2.1150        2.0
  866        8   866-LOCAL INCSN & REM OF INT FIX DEVICES EXC HIP & FEMUR W CC        DRG               Paid DRG            1.5863        4.2
  867        8   867-LOCAL INCSN & REM OF INT FIX DEVICES EXC HIP & FEMUR W/O CC      DRG               Paid DRG            1.2100        2.6
  874       17   874-LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC                  SURGICAL          Paid Per Diem          N/A       N/A
  875       17   875-LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W/O CC                SURGICAL          Paid Per Diem          N/A       N/A
  876       17   876-CHEMO W ACUTE LEUK AS SDX OR W USE OF HIGH DOSE CHEMO AGENT      DRG               Paid DRG            1.6653        4.4
  877        0   877-ECMO OR TRACH W MV 96+ HRS OR PDX EXC FACE, MOUTH & NECK W M     DRG               Paid DRG           26.1073       46.5
  878        0   878-TRACH W MV 96+ HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ OR      DRG               Paid DRG           15.3487       32.0
  879        1   879-CRANIOTOMY W IMPLANT OF CHEMO AGENT OR ACUTE COMPLEX CNS PDX     DRG               Paid DRG            5.7456       11.4
  880        1   880-ACUTE ISCHEMIC STOKE W USE OF THROMBOLYTIC AGENT                 MEDICAL           Paid Per Diem          N/A       N/A
  881        4   881-RESPIRATORY SYSTEM DIAGNOSIS W MV 96+ HRS                        DRG               Paid DRG            7.5473       15.3




5/16/2012                                                        Page 11 of 12                                       Tentative and Preliminary
                                                                     Washington State Medicaid
                                                                     Inpatient System Rebasing
                                                                       Payment Type by DRG


                                                                                                                                                               Average
                                                          Version 23.0                                                                Payment        Relative Length of
 DRG     MDC                                           DRG and Description                                       Type of Service      Method         Weight     Stay

  882          4   882-RESPIRATORY SYSTEM DIAGNOSIS W MV < 96 HRS                                                DRG               Paid DRG            2.7192        6.4
  883          6   883-LAPROSCOPIC APPENDECTOMY                                                                  DRG               Paid DRG            1.0176        2.1
  884          8   884-SPINAL FUSION EXC CERV W CURVATURE OF THE SPINE OR MALIGNANC                              DRG               Paid DRG            7.2978        5.3
  885         14   885-OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE                                               DRG               Paid DRG            1.0668        3.5
  886         14   886-OTHER ANTEPARTUM DIAGNOSES W/O O.R.PROCEDURE                                              DRG               Paid DRG            0.6277        3.1


Bariatrics:        Procedure codes 4431, 4438, 4439, 4468, or 4495 at University of Washington Medical Center,   BARIATRICS        Per Case
                   Sacred Heart Medical Center and Oregon Health Sciences University Hospital only



CUP:               Revenue code 129                                                                              CUP               Paid Per Diem




5/16/2012                                                                       Page 12 of 12                                                   Tentative and Preliminary

				
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