dqe department of health state of new york€¦ · • column 9: medical rehabilitation billing...

STATE OF NEW YORKDQE DEPARTMENT OF HEALTH

Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, New York 12237

Richard F. Dames, M.Q.

James W. Clyne, Jr.Commissioner

Executive Deputy Commissioner

April 13, 2010

Mr. Robert E. BelotenChairmanNew York State Worker' s Compensation Board20 Park StreetAlbany, NY 12207

Dear Mr. Beloten:

The Office of Health Insurance Programs has calculated revised rates of reimbursementfor the period December 1, 2009 through December 31, 2009 and initial rates of reimbursementfor the period January 1, 2010 through March 31, 2010 for hospital inpatient services rendered topatients covered under the Workers' Compensation Law, the Volunteer Firefighters' BenefitLaw, the Volunteer Ambulance Workers' Benefit, and the Comprehensive Motor VehicleInsurance Reparations Act.

Pursuant to section 2807(4) of the Public Health Law, I hereby certify to you that therates appearing on the enclosed schedules have been developed in accordance with section 2807-c of the Public Health Law, as amended by the Health Care Reform Act, and Part 86-1 of theTitle 10 (Health) of the Codes, Rules and Regulations of the State of New York.

Sincerely,

VIAF

Donna FrescatoreDeputy CommissionerOffice of Health Insurance Programs

Enclosure(s)

1

STATE OF NEW YORKDQE DEPARTMENT OF HEALTH

Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, New York 12237

Richard F. Daines, M.D.

James W. Clyne, Jr.Commissioner

Executive Deputy Commissioner

April 13, 2010

Mr. Robert E. BelotenChairmanNew York State Worker's Compensation Board20 Park StreetAlbany, NY 11207

Dear Mr. Beloten:

Enclosed please find the certification letter and schedules on revised hospitalreimbursement rates for services rendered to patients covered under the Workers' CompensationBenefit Law, the Volunteer Ambulance Workers' Benefit Law and the Comprehensive MotorVehicle Reparation Act for the period December 1, 2009 through December 31, 2009 as well asinitial rates for the period January 1, 2010 through March 31, 2010. Rates of payment for

inpatient services for these payors is to be based upon rates determined for state governmentalagencies (Medicaid) in accordance with Article 2807-c(b-1) of the Public Health Law.

The formula on which these rates are based was promulgated in accordance with Article28 of the Public Health Law as recently amended by Chapter 58 of the Laws of 2009 (Respectivesections attached). With the enactment of these amendments the methodology and base yearused to establish Medicaid rates has been changed significantly.

The revised rates for the period December 1, 2009 through December 31, 2009 reflect thecorrection to some facilities rates due to updated data provided by those hospitals. However amajority of the rate components, previously provided have not changed. The initial rates for theperiod January 1, 2010 through March 31, 2010 reflect the corrections noted, but also reflect theimplementation of budgeted 2010 capital in accordance with subdivision 10 of Article 2807-C ofthe Public Health Law.

The schedules attached have been calculated in accordance with these provisions and thevarious schedules and components are described in detail below:

Schedule of Worker's Comp/No Fault Inpatient Case Payment Rates:• Column 1: Admission Case Payment Rate: This column contains the admission rate

that is based upon the statewide price (column 3) adjusted by the Institutional SpecificAdjustment Factor (Column 4) and reflects the average case mix using the new AllPatient Refined DRGs (APR DRG).Column 2: Discharge Case Payment Rate: This reflects the statewide base price(column 3) adjusted by Column 4.

2

• Column 3: Statewide Base Price: This is the new statewide base price.• Column 4: Institutional Specific Adjustment Factor (ISAF): Hospital specific

adjustment to reflect wage differences (Wage Equalization Factor).• Column 5: High Cost Charge Convertor: Charge convertor to reduce hospital charges

for cost outlier payments.• Column 6: Indirect Medical Education (IME)%: This is the indirect medical

education percentage.• Column 7: Direct Medical Education (DME) Add on: This is the Direct Medical

Education per discharge add on.• Column 8: Capital Per Discharge plus non-comparables: This is the capital and non-

comparable per discharge to be included after application of the Service IntensityWeights (SIW's).

• Column 9: Capital Per Diem: This is the capital per diem to be used when a transferpayment on a per diem is being made.

• Column 10: ALC Per Diem: This is the Alternate Level of Care per diem for thosepatients who no longer requires acute hospital care and are waiting placement ordischarge.

• Column 11: Public Goods Pool Surcharge: This is the surcharge percentageobligation as authorized by Public Health Law Section 2807-j when payment is madedirectly to the pool.

• Column 12: Additional Public Goods Pool Surcharge: This is the additionalsurcharge applicable if Public Goods pool is paid to the hospital and payor is not anelected payor.

Schedule of Workers' Compensation /No Fault (WCNF) Inpatient Exempt Unit Rates:These are the per diem rates that are applicable for exempt hospital and exempt units within ageneral hospital in accordance with Article 2807-c of the Public Health Law.

• Column 1: Specialty Acute Hospital Billing Rate (with DME): This per diem is forspecialty long term acute hospitals, cancer hospitals, or Children's Hospitals.

• Column 2: Specialty Acute ALC Per Diem: Alternate Level of Care per diem forthose patients who no longer require specialty acute services and are awaiting placementor discharge, in these types of hospitals.

• Column 3 & Column 4: Psychiatric Per Diem: Please note that new psychiatricexempt unit rates have not been finalized at this time, so plans should continue to useexisting psychiatric per diems that were transmitted effective July 1, 2008. Furtherinformation to be provided in near future.

• Column 5: Chemically Dependency Billing Rate: Per diem for Alcohol or DrugRehabilitation programs which have been combined into one service type.

• Column 6: Chemically Dependency ALC Per Diem: Alternate Level of Care perdiem for those patients who no longer require acute services and are waiting placement ordischarge.

• Column 7: Critical Access Hospital Billing Rate: Per Diem to be paid to thosehospitals that are designated as critical access hospitals.

3

• Column 8: Critical Access Hospital ALC Per Diem: Alternative Level of Care perdiem to be paid for patients who no longer require acute care and is waiting placement ordischarge.

• Column 9: Medical Rehabilitation Billing Rate: Per diem for medical rehabilitationservices.

• Column 10: Medical Rehabilitation ALC Per Diem: Alternative Level of Care perdiem to be paid for patients who no longer require acute care and is waiting placement ordischarge.

• Column 11: Detox Medically Managed Billing Rate: Per diem to be paid to hospitalsfor medically managed services with certified detox program by OASAS. (Updated ratesto be provided in near future).

• Column 12: Detox Medically Supervised Billing Rate: Per diem to be paid tohospitals for medically supervised service with certified detox program by OASAS.(Updated rates to be provided in near future).

• Column 13: Same as Column 11 under Acute section• Column 14: Same as Column 12

Sample Payment Calculation Worksheets - With the inception of Medicaid reform andupdates as authorized in Chapter 58 of the Laws of 2009, these payment schedules have beenupdated to incorporate the various changes in payment methodologies for inlier, transfers, costoutliers, and exempt unit services.

APR-DRG's & Service Intensity Weights (SIW's): This schedule contains the new APR-DRG listing with each severity level and the service intensity weight applicable as well as theStatewide Average Length of Stay for each (ALOS).

Cost Outlier Thresholds: This schedule contains the specific cost threshold for each of theAPR-DRG's and applies to any severity level within each of the APR-DRG's.

Should you have any questions or require further information please do not hesitate tocontact Mr. John W. Gahan Jr., Director, Bureau of Primary and Acute Care Reimbursement at(518) 474-3267.

Sincerely,

Division of Health Care Financing

4

SCHEDULE OF WORKER'S COMP/NO FAULT (WCNF)INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/10 - 3/31/10

(1) (2) (3) (4) (5) (6)

ADMISSION RATE DISCHARGE RATE STATEWIDE PRICE ISAF HIGH COST CC's IME %'s

ADMISSION CASE PAYMENT RATE (EXCLUDING PHL § 2807‐

c(33))

DISCHARGE CASE PAYMENT RATE

(EXCLUDING PHL § 2807‐c(33))

STATEWIDE BASE PRICE (EXCLUDING PHL § 2807‐

c(33))

INSTITUTION‐SPECIFIC

ADJUSTMENT FACTOR (ISAF)

HIGH COST CHARGE CONVERTOR

INDIRECT MEDICAL

EDUCATION (IME) %

OPCERT HOSPITAL NAME1623001 ADIRONDACK MEDICAL CENTER $5,628.29 $5,554.42 $6,747.35 0.8232 0.633439 0.00%0101005 ALB MED CTR SO CLINICAL CAMP $17,891.65 $5,922.59 $6,747.35 0.8436 0.788103 4.05%0101000 ALBANY MEDICAL CTR HOSP $12,612.87 $7,040.49 $6,747.35 0.8699 0.392027 19.95%3701000 ALBERT LINDLEY LEE MEM HOSP $4,321.23 $4,890.48 $6,747.35 0.7248 0.521022 0.00%1624000 ALICE HYDE MEDICAL CENTER $3,287.49 $5,430.27 $6,747.35 0.8048 0.573986 0.00%0701000 ARNOT OGDEN MEDICAL CTR $4,157.80 $5,420.15 $6,747.35 0.8033 0.468437 0.00%0501000 AUBURN MEMORIAL HOSPITAL $3,379.43 $5,817.57 $6,747.35 0.8622 0.491137 0.00%3801000 AURELIA OSBORN FOX MEM HOSP $3,239.82 $5,350.65 $6,747.35 0.7930 0.668487 0.00%7002001 BELLEVUE HOSPITAL CENTER $15,179.07 $8,711.48 $6,747.35 1.0233 0.790023 26.17%5501000 BENEDICTINE HOSPITAL $5,247.25 $6,010.79 $6,747.35 0.8726 0.312028 2.09%1427000 BERTRAND CHAFFEE HOSPITAL $4,635.46 $4,717.07 $6,747.35 0.6991 0.602722 0.00%7001041 BETH ISRAEL / KINGS HIGHWAY $8,058.92 $7,862.01 $6,747.35 1.1652 0.185338 0.00%7002002 BETH ISRAEL MEDICAL CENTER $11,586.04 $9,489.00 $6,747.35 1.1304 0.335516 24.41%3535001 BON SECOURS COMMUNITY HOSP $4,296.34 $6,190.69 $6,747.35 0.9175 0.309085 0.00%7000001 BRONX‐LEBANON HOSPITAL CTR $10,892.53 $9,133.76 $6,747.35 1.0648 0.730071 27.13%7001002 BROOKDALE HOSPITAL MED CTR $12,301.60 $8,540.89 $6,747.35 1.0476 0.584224 20.83%5123000 BROOKHAVEN MEMORIAL HOSP $5,992.05 $6,870.83 $6,747.35 1.0183 0.209413 0.00%7001003 BROOKLYN HOSPITAL $9,003.82 $8,374.69 $6,747.35 1.0296 0.543652 20.55%0601000 BROOKS MEMORIAL HOSPITAL $2,843.98 $4,941.76 $6,747.35 0.7324 0.697443 0.00%4429000 CANTON‐POTSDAM HOSPITAL $3,074.96 $5,353.35 $6,747.35 0.7934 0.600233 0.00%2238001 CARTHAGE AREA HOSPITAL INC $2,435.35 $4,957.95 $6,747.35 0.7348 0.440857 0.00%5263000 CATSKILL REGIONAL MED CTR $5,281.75 $6,173.15 $6,747.35 0.9149 0.436770 0.00%5401001 CAYUGA MEDICAL CENTER $3,898.70 $6,016.51 $6,747.35 0.8812 0.759452 1.19%0901001 CHAMPLAIN VALLEY PHYS $3,786.29 $5,669.80 $6,747.35 0.8403 0.439962 0.00%0824000 CHENANGO MEMORIAL HOSP $3,012.39 $5,141.48 $6,747.35 0.7620 0.501189 0.00%4401000 CLAXTON‐HEPBURN MED CTR $3,020.61 $5,190.06 $6,747.35 0.7692 0.665019 0.00%3421000 CLIFTON SPRINGS HOSPITAL $6,086.98 $4,688.06 $6,747.35 0.6948 0.583462 0.00%4720001 COBLESKILL REGIONAL HOSP $3,408.31 $5,130.68 $6,747.35 0.7604 0.920860 0.00%1001000 COLUMBIA MEMORIAL HOSPITAL $4,381.90 $5,536.20 $6,747.35 0.8205 0.462135 0.00%3301000 COMM‐GEN / GREATER SYRACUSE $3,752.63 $6,358.89 $6,747.35 0.9264 0.534457 1.73%2625000 COMMUNITY MEMORIAL HOSPITAL $2,897.24 $5,427.57 $6,747.35 0.8044 0.533932 0.00%7001009 CONEY ISLAND HOSPITAL $9,062.87 $7,975.10 $6,747.35 1.0110 0.680783 16.91%5001000 CORNING HOSPITAL $3,694.66 $5,922.82 $6,747.35 0.8778 0.567279 0.00%

5


OPCERT HOSPITAL NAME1623001 ADIRONDACK MEDICAL CENTER0101005 ALB MED CTR SO CLINICAL CAMP0101000 ALBANY MEDICAL CTR HOSP3701000 ALBERT LINDLEY LEE MEM HOSP1624000 ALICE HYDE MEDICAL CENTER0701000 ARNOT OGDEN MEDICAL CTR0501000 AUBURN MEMORIAL HOSPITAL3801000 AURELIA OSBORN FOX MEM HOSP7002001 BELLEVUE HOSPITAL CENTER5501000 BENEDICTINE HOSPITAL1427000 BERTRAND CHAFFEE HOSPITAL7001041 BETH ISRAEL / KINGS HIGHWAY7002002 BETH ISRAEL MEDICAL CENTER3535001 BON SECOURS COMMUNITY HOSP7000001 BRONX‐LEBANON HOSPITAL CTR7001002 BROOKDALE HOSPITAL MED CTR5123000 BROOKHAVEN MEMORIAL HOSP7001003 BROOKLYN HOSPITAL0601000 BROOKS MEMORIAL HOSPITAL4429000 CANTON‐POTSDAM HOSPITAL2238001 CARTHAGE AREA HOSPITAL INC5263000 CATSKILL REGIONAL MED CTR5401001 CAYUGA MEDICAL CENTER0901001 CHAMPLAIN VALLEY PHYS0824000 CHENANGO MEMORIAL HOSP4401000 CLAXTON‐HEPBURN MED CTR3421000 CLIFTON SPRINGS HOSPITAL4720001 COBLESKILL REGIONAL HOSP1001000 COLUMBIA MEMORIAL HOSPITAL3301000 COMM‐GEN / GREATER SYRACUSE2625000 COMMUNITY MEMORIAL HOSPITAL7001009 CONEY ISLAND HOSPITAL5001000 CORNING HOSPITAL

(7) (8) (9) (10) (11) (12)

DME RATE CAPITAL ‐ PER DISCH CAPITAL ‐ PER DIEM ALC

DIRECT MEDICAL EDUCATION (DME)

ADD‐ON

CAPITAL PER DISCHARGE PLUS NON‐COMPARABLES: AMBULANCE, SCHOOL OF NURSING & TEACHING HOSPITALS PHYS

COSTS ADD‐ONS (Excludes Transition Add‐ons) CAPITAL PER DIEM ALC PER DIEM

PUBLIC GOODS POOL SURCHARGE

ADDITIONAL PUBLIC GOODS

POOL SURCHARGE

**(PER DISCH)** **(PER DAY**)$0.00 $383.05 $83.35 $171.74 9.63% 28.27%$48.67 $845.40 $432.31 $171.74 9.63% 28.27%$738.38 $630.03 $112.80 $171.74 9.63% 28.27%$0.00 $0.00 $0.00 $171.74 9.63% 28.27%$0.00 $187.44 $47.36 $171.74 9.63% 28.27%$0.00 $466.02 $94.10 $171.74 9.63% 28.27%$0.00 $227.14 $53.01 $171.74 9.63% 28.27%$0.00 $293.51 $69.52 $171.74 9.63% 28.27%

$3,216.46 $1,936.36 $149.10 $261.20 9.63% 28.27%$91.80 $372.03 $68.44 $171.74 9.63% 28.27%$0.00 $94.45 $25.07 $171.74 9.63% 28.27%

$641.90 $99.33 $16.22 $261.20 9.63% 28.27%$1,432.82 $821.99 $163.01 $261.20 9.63% 28.27%

$0.00 $196.37 $48.82 $171.74 9.63% 28.27%$1,912.22 $470.08 $78.98 $261.20 9.63% 28.27%$1,658.80 $383.85 $63.00 $261.20 9.63% 28.27%

$0.00 $318.29 $58.57 $261.20 9.63% 28.27%$768.15 $293.88 $56.34 $261.20 9.63% 28.27%$0.00 $225.08 $50.73 $171.74 9.63% 28.27%$0.00 $347.51 $98.49 $171.74 9.63% 28.27%$0.00 $266.13 $74.93 $171.74 9.63% 28.27%$0.00 $402.42 $112.36 $171.74 9.63% 28.27%$0.00 $380.98 $98.77 $171.74 9.63% 28.27%$0.00 $607.30 $104.15 $171.74 9.63% 28.27%$0.00 $211.88 $46.01 $171.74 9.63% 28.27%$0.00 $309.87 $76.78 $171.74 9.63% 28.27%$0.00 $235.61 $50.22 $171.74 9.63% 28.27%$0.00 $391.09 $52.53 $171.74 9.63% 28.27%$0.00 $304.43 $68.49 $171.74 9.63% 28.27%$24.42 $260.71 $55.17 $171.74 9.63% 28.27%$0.00 $278.76 $74.55 $171.74 9.63% 28.27%

$1,732.16 $3,714.73 $134.75 $261.20 9.63% 28.27%$0.00 $189.77 $55.76 $171.74 9.63% 28.27%

WCNF SURCHARGES

6


(1) (2) (3) (4) (5) (6)



c(33))




c(33))




INDIRECT MEDICAL

EDUCATION (IME) %

OPCERT HOSPITAL NAME

1101000 CORTLAND REGIONAL MED CTR $3,076.95 $5,418.12 $6,747.35 0.8030 0.684025 0.00%3301008 CROUSE HOSPITAL $7,155.07 $6,715.40 $6,747.35 0.9458 0.556811 5.23%4423000 E J NOBLE HOSP / GOUVERNEUR $2,494.35 $4,619.91 $6,747.35 0.6847 0.595681 0.00%5127000 EASTERN LONG ISLAND HOSPITAL $5,232.46 $6,682.58 $6,747.35 0.9904 0.416567 0.00%3101000 EASTERN NIAGARA HOSPITAL $3,604.47 $5,453.88 $6,747.35 0.8083 0.599802 0.00%4601001 ELLIS HOSPITAL $5,925.41 $5,962.64 $6,747.35 0.8401 0.293822 5.19%7003000 ELMHURST HOSPITAL CTR $10,543.35 $8,891.07 $6,747.35 1.0763 0.574950 22.43%1401005 ERIE COUNTY MEDICAL CENTER $14,011.03 $7,568.14 $6,747.35 0.9218 0.483063 21.68%3429000 F F THOMPSON HOSPITAL $3,110.42 $4,758.91 $6,747.35 0.7053 0.573882 0.00%3202003 FAXTON‐ST LUKES HEALTHCARE $4,185.90 $5,642.70 $6,747.35 0.8308 0.481342 0.66%7003001 FLUSHING HOSPITAL $8,700.79 $8,215.75 $6,747.35 1.0332 0.529894 17.85%7003013 FOREST HILLS HOSPITAL $7,293.77 $8,174.64 $6,747.35 1.1309 0.397327 7.13%2910000 FRANKLIN HOSPITAL $8,225.87 $6,724.82 $6,747.35 0.9829 0.288633 1.40%3402000 GENEVA GENERAL HOSPITAL $3,822.64 $4,923.54 $6,747.35 0.7297 0.610428 0.00%2901000 GLEN COVE HOSPITAL $8,887.29 $7,928.68 $6,747.35 1.1288 0.348526 4.10%5601000 GLENS FALLS HOSPITAL $3,872.61 $5,497.74 $6,747.35 0.8148 0.516468 0.00%4329000 GOOD SAMARITAN / SUFFERN $8,594.31 $6,908.61 $6,747.35 1.0239 0.198706 0.00%5154001 GOOD SAMARITAN / WEST ISLIP $7,139.54 $7,223.12 $6,747.35 1.0148 0.250920 5.49%7002009 HARLEM HOSPITAL CENTER $11,893.87 $9,303.12 $6,747.35 1.0509 1.002754 31.20%2701001 HIGHLAND HOSP OF ROCHESTER $5,538.23 $6,406.62 $6,747.35 0.8599 0.610190 10.42%7002012 HOSPITAL FOR SPECIAL SURGERY $20,802.30 $9,621.30 $6,747.35 1.1809 0.380113 20.75%5901000 HUDSON VALLEY HOSPITAL CTR $5,232.23 $6,453.17 $6,747.35 0.9564 0.297442 0.00%5153000 HUNTINGTON HOSPITAL $6,202.64 $7,192.95 $6,747.35 1.0580 0.319587 0.76%7001046 INTERFAITH MEDICAL CENTER $10,615.26 $9,316.70 $6,747.35 1.0538 0.311264 31.03%5022000 IRA DAVENPORT MEMORIAL HOSP $3,858.33 $5,082.10 $6,747.35 0.7532 0.571873 0.00%7000002 JACOBI MEDICAL CENTER $14,109.73 $9,528.20 $6,747.35 1.1093 0.786295 27.30%7003003 JAMAICA HOSPITAL $9,344.50 $8,811.90 $6,747.35 1.1241 0.600097 16.18%5149000 JOHN T MATHER MEMORIAL HOSP $9,799.04 $6,940.32 $6,747.35 1.0286 0.355978 0.00%0228000 JONES MEMORIAL HOSPITAL $3,100.38 $5,011.93 $6,747.35 0.7428 0.590215 0.00%1401014 KALEIDA HEALTH $9,591.41 $7,030.29 $6,747.35 0.9274 0.432257 12.35%1401014 KALEIDA HEALTH (MILLARD) $9,591.41 $7,030.29 $6,747.35 0.9274 0.432257 12.35%1401002 KALEIDA HLTH/WOMAN&CHILDRENS $10,002.92 $7,808.56 $6,747.35 0.9147 0.423450 26.52%1404000 KENMORE MERCY HOSPITAL $6,761.42 $5,528.10 $6,747.35 0.8193 0.435233 0.00%

7



1101000 CORTLAND REGIONAL MED CTR3301008 CROUSE HOSPITAL4423000 E J NOBLE HOSP / GOUVERNEUR5127000 EASTERN LONG ISLAND HOSPITAL3101000 EASTERN NIAGARA HOSPITAL4601001 ELLIS HOSPITAL7003000 ELMHURST HOSPITAL CTR1401005 ERIE COUNTY MEDICAL CENTER3429000 F F THOMPSON HOSPITAL3202003 FAXTON‐ST LUKES HEALTHCARE7003001 FLUSHING HOSPITAL7003013 FOREST HILLS HOSPITAL2910000 FRANKLIN HOSPITAL3402000 GENEVA GENERAL HOSPITAL2901000 GLEN COVE HOSPITAL5601000 GLENS FALLS HOSPITAL4329000 GOOD SAMARITAN / SUFFERN5154001 GOOD SAMARITAN / WEST ISLIP7002009 HARLEM HOSPITAL CENTER2701001 HIGHLAND HOSP OF ROCHESTER7002012 HOSPITAL FOR SPECIAL SURGERY5901000 HUDSON VALLEY HOSPITAL CTR5153000 HUNTINGTON HOSPITAL7001046 INTERFAITH MEDICAL CENTER5022000 IRA DAVENPORT MEMORIAL HOSP7000002 JACOBI MEDICAL CENTER7003003 JAMAICA HOSPITAL5149000 JOHN T MATHER MEMORIAL HOSP0228000 JONES MEMORIAL HOSPITAL1401014 KALEIDA HEALTH1401014 KALEIDA HEALTH (MILLARD)1401002 KALEIDA HLTH/WOMAN&CHILDRENS1404000 KENMORE MERCY HOSPITAL

(7) (8) (9) (10) (11) (12)



ADD‐ON





POOL SURCHARGE

**(PER DISCH)** **(PER DAY**)

WCNF SURCHARGES

$0.00 $369.50 $57.54 $171.74 9.63% 28.27%$144.19 $432.03 $72.98 $171.74 9.63% 28.27%$2.83 $206.56 $41.80 $171.74 9.63% 28.27%$0.00 $596.10 $116.57 $261.20 9.63% 28.27%$0.00 $166.69 $35.30 $171.74 9.63% 28.27%$21.80 $387.81 $79.04 $171.74 9.63% 28.27%

$1,805.20 $2,046.70 $123.38 $261.20 9.63% 28.27%$651.75 $578.09 $94.78 $171.74 9.63% 28.27%$0.00 $359.09 $91.80 $171.74 9.63% 28.27%$0.15 $273.25 $56.13 $171.74 9.63% 28.27%

$976.35 $666.04 $47.30 $261.20 9.63% 28.27%$167.93 $520.50 $105.02 $261.20 9.63% 28.27%$248.89 $255.63 $43.28 $261.20 9.63% 28.27%$0.00 $321.27 $63.33 $171.74 9.63% 28.27%

$136.40 $544.32 $90.30 $261.20 9.63% 28.27%$0.00 $474.13 $103.69 $171.74 9.63% 28.27%$0.00 $320.29 $79.10 $261.20 9.63% 28.27%

$268.90 $302.40 $59.73 $261.20 9.63% 28.27%$3,300.58 $1,773.69 $90.74 $261.20 9.63% 28.27%$127.84 $271.46 $58.95 $171.74 9.63% 28.27%

$1,651.11 $1,427.11 $359.58 $261.20 9.63% 28.27%$0.00 $476.84 $96.09 $261.20 9.63% 28.27%$16.70 $401.03 $87.29 $261.20 9.63% 28.27%

$1,018.12 $702.25 $119.31 $261.20 9.63% 28.27%$0.00 $145.02 $36.90 $171.74 9.63% 28.27%

$2,750.20 $2,473.92 $134.95 $261.20 9.63% 28.27%$907.10 $528.05 $60.51 $261.20 9.63% 28.27%$0.00 $262.96 $44.28 $261.20 9.63% 28.27%$0.00 $376.14 $104.44 $171.74 9.63% 28.27%

$339.54 $656.87 $126.74 $171.74 9.63% 28.27%$339.54 $656.87 $126.74 $171.74 9.63% 28.27%$495.99 $491.73 $116.90 $171.74 9.63% 28.27%$0.00 $500.37 $83.99 $171.74 9.63% 28.27%

8


(1) (2) (3) (4) (5) (6)



c(33))




c(33))




INDIRECT MEDICAL

EDUCATION (IME) %


7001016 KINGS COUNTY HOSPITAL CENTER $13,517.92 $9,134.91 $6,747.35 1.0145 0.723330 33.45%7001033 KINGSBROOK JEWISH MED CTR $14,303.84 $8,876.87 $6,747.35 1.1482 0.336873 14.58%5501001 KINGSTON HOSPITAL $5,922.46 $6,205.48 $6,747.35 0.8734 0.462225 5.30%2728001 LAKESIDE MEMORIAL HOSPITAL $3,574.51 $4,906.00 $6,747.35 0.7271 0.424993 0.00%5922000 LAWRENCE HOSPITAL $5,770.14 $6,729.81 $6,747.35 0.9974 0.381174 0.00%7002017 LENOX HILL HOSPITAL $13,183.18 $8,097.74 $6,747.35 1.0407 0.212152 15.32%2424000 LEWIS COUNTY GENERAL HOSP $2,861.88 $5,507.86 $6,747.35 0.8163 0.701273 0.00%7000008 LINCOLN MEDICAL $9,935.22 $8,664.53 $6,747.35 1.0321 0.868774 24.42%2902000 LONG BEACH MEDICAL CENTER $8,487.43 $6,767.01 $6,747.35 0.9032 0.305201 11.04%7001017 LONG ISLAND COLLEGE HOSPITAL $9,539.25 $8,561.67 $6,747.35 1.0333 0.409851 22.80%7003004 LONG ISLAND JEWISH $14,189.52 $9,473.25 $6,747.35 1.0882 0.318139 29.02%7001019 LUTHERAN MEDICAL CENTER $9,850.33 $8,510.62 $6,747.35 1.0172 0.579842 24.00%7001020 MAIMONIDES MEDICAL CENTER $14,958.79 $9,891.47 $6,747.35 1.1904 0.313754 23.15%3824000 MARY IMOGENE BASSETT HOSP $5,087.25 $5,744.81 $6,747.35 0.7538 0.496744 12.95%4402000 MASSENA MEMORIAL HOSPITAL $3,038.30 $5,424.87 $6,747.35 0.8040 0.632200 0.00%3622000 MEDINA MEMORIAL HLTH CARE $2,903.49 $4,364.86 $6,747.35 0.6469 0.865467 0.00%0101003 MEMORIAL HOSP OF ALBANY $6,421.03 $5,439.71 $6,747.35 0.8062 0.530937 0.00%1401008 MERCY HOSPITAL OF BUFFALO $5,443.50 $6,144.20 $6,747.35 0.8840 0.461137 3.01%2909000 MERCY MEDICAL CENTER $6,916.20 $6,880.61 $6,747.35 1.0167 0.316249 0.30%7002021 METROPOLITAN HOSPITAL CENTER $9,833.52 $8,812.64 $6,747.35 1.0211 0.781170 27.91%7000006 MONTEFIORE MEDICAL CENTER $14,362.54 $9,770.78 $6,747.35 1.1229 0.277820 28.96%7003015 MOUNT SINAI HOSP OF QUEENS $7,062.79 $6,781.76 $6,747.35 1.0051 0.388988 0.00%7002024 MOUNT SINAI HOSPITAL $17,447.29 $10,067.58 $6,747.35 1.1206 0.423808 33.15%3121001 MOUNT ST MARYS HOSPITAL $4,562.00 $5,731.87 $6,747.35 0.8495 0.550469 0.00%5903000 MOUNT VERNON HOSPITAL $10,385.64 $7,797.55 $6,747.35 1.0550 0.560216 9.54%2950002 NASSAU UNIV MED CTR $8,984.43 $9,297.20 $6,747.35 1.1324 0.628195 21.68%1701000 NATHAN LITTAUER HOSPITAL $3,246.90 $5,245.39 $6,747.35 0.7774 0.534222 0.00%2952006 NEW ISLAND HOSPITAL $8,808.56 $6,811.45 $6,747.35 1.0095 0.341489 0.00%7002000 NEW YORK DOWNTOWN HOSP $7,603.13 $8,450.25 $6,747.35 1.0608 1.666134 18.06%3102000 NIAGARA FALLS MEMORIAL $4,182.49 $5,458.86 $6,747.35 0.7768 0.490218 4.15%2527000 NICHOLAS H NOYES MEMORIAL $3,307.30 $5,000.46 $6,747.35 0.7411 0.464593 0.00%7000024 NORTH CENTRAL BRONX HOSPITAL $7,122.60 $8,688.03 $6,747.35 1.1408 0.755691 12.87%7002052 NORTH GENERAL HOSPITAL $8,201.79 $7,519.08 $6,747.35 1.0127 0.648001 10.04%

9



7001016 KINGS COUNTY HOSPITAL CENTER7001033 KINGSBROOK JEWISH MED CTR5501001 KINGSTON HOSPITAL2728001 LAKESIDE MEMORIAL HOSPITAL5922000 LAWRENCE HOSPITAL7002017 LENOX HILL HOSPITAL2424000 LEWIS COUNTY GENERAL HOSP7000008 LINCOLN MEDICAL2902000 LONG BEACH MEDICAL CENTER7001017 LONG ISLAND COLLEGE HOSPITAL7003004 LONG ISLAND JEWISH7001019 LUTHERAN MEDICAL CENTER7001020 MAIMONIDES MEDICAL CENTER3824000 MARY IMOGENE BASSETT HOSP4402000 MASSENA MEMORIAL HOSPITAL3622000 MEDINA MEMORIAL HLTH CARE0101003 MEMORIAL HOSP OF ALBANY1401008 MERCY HOSPITAL OF BUFFALO2909000 MERCY MEDICAL CENTER7002021 METROPOLITAN HOSPITAL CENTER7000006 MONTEFIORE MEDICAL CENTER7003015 MOUNT SINAI HOSP OF QUEENS7002024 MOUNT SINAI HOSPITAL3121001 MOUNT ST MARYS HOSPITAL5903000 MOUNT VERNON HOSPITAL2950002 NASSAU UNIV MED CTR1701000 NATHAN LITTAUER HOSPITAL2952006 NEW ISLAND HOSPITAL7002000 NEW YORK DOWNTOWN HOSP3102000 NIAGARA FALLS MEMORIAL2527000 NICHOLAS H NOYES MEMORIAL7000024 NORTH CENTRAL BRONX HOSPITAL7002052 NORTH GENERAL HOSPITAL

(7) (8) (9) (10) (11) (12)



ADD‐ON





POOL SURCHARGE


WCNF SURCHARGES

$3,118.75 $2,545.40 $191.82 $261.20 9.63% 28.27%$1,393.32 $334.37 $50.73 $261.20 9.63% 28.27%$263.07 $466.58 $95.13 $171.74 9.63% 28.27%$0.00 $140.12 $41.04 $171.74 9.63% 28.27%$0.00 $476.43 $106.80 $261.20 9.63% 28.27%

$1,205.81 $1,090.40 $177.93 $261.20 9.63% 28.27%$0.00 $285.99 $86.33 $171.74 9.63% 28.27%

$1,656.26 $2,556.71 $84.31 $261.20 9.63% 28.27%$536.87 $469.97 $67.48 $261.20 9.63% 28.27%

$1,199.34 $893.54 $147.13 $261.20 9.63% 28.27%$1,261.37 $639.95 $134.38 $261.20 9.63% 28.27%$1,316.74 $447.12 $47.83 $261.20 9.63% 28.27%$1,725.98 $1,704.56 $134.88 $261.20 9.63% 28.27%$367.32 $532.82 $120.94 $171.74 9.63% 28.27%$2.54 $235.50 $65.76 $171.74 9.63% 28.27%$39.27 $152.14 $35.47 $171.74 9.63% 28.27%$0.00 $499.31 $75.75 $171.74 9.63% 28.27%$50.74 $461.21 $96.07 $171.74 9.63% 28.27%$72.06 $357.67 $68.37 $261.20 9.63% 28.27%

$2,503.16 $1,233.40 $112.21 $261.20 9.63% 28.27%$2,861.35 $695.35 $131.37 $261.20 9.63% 28.27%

$41.63 $405.66 $72.43 $261.20 9.63% 28.27%$1,509.30 $786.09 $159.00 $261.20 9.63% 28.27%

$0.00 $235.51 $54.14 $171.74 9.63% 28.27%$1,097.20 $554.62 $29.98 $261.20 9.63% 28.27%$887.49 $357.34 $55.78 $261.20 9.63% 28.27%$0.00 $243.71 $57.32 $171.74 9.63% 28.27%$16.34 $314.74 $62.68 $261.20 9.63% 28.27%$967.99 $1,605.18 $349.05 $261.20 9.63% 28.27%$90.53 $414.68 $100.28 $171.74 9.63% 28.27%$0.00 $305.47 $83.93 $171.74 9.63% 28.27%

$1,505.78 $1,051.09 $108.76 $261.20 9.63% 28.27%$1,378.23 $1,015.45 $165.68 $261.20 9.63% 28.27%

10


(1) (2) (3) (4) (5) (6)



c(33))




c(33))




INDIRECT MEDICAL

EDUCATION (IME) %


2951001 NORTH SHORE UNIVERSITY HOSP $15,667.68 $9,107.44 $6,747.35 1.1617 0.293430 16.19%1327000 NORTHERN DUTCHESS HOSPITAL $4,477.80 $6,441.02 $6,747.35 0.9546 0.411690 0.00%5920000 NORTHERN WESTCHESTER HOSP $4,483.75 $6,825.62 $6,747.35 1.0116 0.535071 0.00%7001008 NY COMMUNITY / BROOKLYN $7,779.10 $7,578.28 $6,747.35 1.1128 0.421484 0.93%7002026 NY EYE AND EAR INFIRMARY $11,019.70 $8,002.29 $6,747.35 1.0217 0.420274 16.08%7003010 NY MED CTR OF QUEENS $10,083.97 $8,641.84 $6,747.35 1.0990 0.379023 16.54%7001021 NY METHODIST HOSP / BROOKLYN $10,501.77 $8,417.72 $6,747.35 1.0683 0.471205 16.78%7002054 NY PRESBYTERIAN HOSPITAL $15,761.95 $9,588.25 $6,747.35 1.1184 0.385719 27.06%7002054 NY PRESBYTERIAN HOSPITAL (ALLEN) $15,761.95 $9,588.25 $6,747.35 1.1184 0.385719 27.06%7002054 NY PRESBYTERIAN HOSPITAL (PRESBY) $15,761.95 $9,588.25 $6,747.35 1.1184 0.385719 27.06%7000025 NY WESTCHESTER SQUARE MED CTR $6,666.48 $6,738.58 $6,747.35 0.9987 0.400254 0.00%4324000 NYACK HOSPITAL $5,439.90 $6,578.67 $6,747.35 0.9750 0.274764 0.00%7002053 NYU HOSPITALS CENTER $15,194.92 $8,648.52 $6,747.35 1.0701 0.393229 19.78%7002053 NYU HOSPITALS CENTER/HOSP FOR JOINT DIS $15,194.92 $8,648.52 $6,747.35 1.0701 0.393229 19.78%0401001 OLEAN GENERAL HOSPITAL $3,530.30 $5,238.61 $6,747.35 0.7681 0.513318 1.08%2601001 ONEIDA HEALTHCARE CENTER $2,612.92 $4,886.43 $6,747.35 0.7242 0.503143 0.00%3523000 ORANGE REGIONAL MED CTR $5,429.63 $6,719.01 $6,747.35 0.9958 0.260719 0.00%3702000 OSWEGO HOSPITAL $3,226.49 $5,552.39 $6,747.35 0.8229 0.567339 0.00%0301001 OUR LADY OF LOURDES MEMORIAL $4,138.52 $5,547.41 $6,747.35 0.8047 0.532027 2.17%5155000 PECONIC BAY MED CTR $4,809.12 $6,748.70 $6,747.35 1.0002 0.240950 0.00%7003006 PENINSULA HOSPITAL CENTER $9,441.57 $7,040.88 $6,747.35 0.9395 0.374040 11.07%5932000 PHELPS MEMORIAL HOSP $3,687.43 $6,747.35 $6,747.35 1.0000 0.372063 0.00%2952005 PLAINVIEW HOSPITAL $6,232.35 $7,755.10 $6,747.35 1.1043 0.342136 4.08%3950000 PUTNAM COMMUNITY HOSPITAL $6,547.04 $6,920.76 $6,747.35 1.0257 0.322529 0.00%7003007 QUEENS HOSPITAL CENTER $8,881.51 $9,070.33 $6,747.35 1.1398 0.807393 17.94%7004010 RICHMOND UNIV MED CTR $8,448.13 $7,778.81 $6,747.35 0.9998 0.279179 15.31%2701003 ROCHESTER GENERAL HOSPITAL $7,111.41 $6,306.67 $6,747.35 0.8491 0.485187 10.08%3201002 ROME HOSPITAL AND MURPHY $3,981.26 $5,200.18 $6,747.35 0.7707 0.478620 0.00%4102002 SAMARITAN HOSPITAL OF TROY $5,379.84 $5,364.82 $6,747.35 0.7951 0.443743 0.00%2201000 SAMARITAN MEDICAL CENTER $3,413.62 $5,752.16 $6,747.35 0.8444 0.535569 0.96%4501000 SARATOGA HOSPITAL $3,955.30 $5,615.14 $6,747.35 0.8322 0.388246 0.00%4102003 SETON HEALTH SYSTEMS $4,378.43 $5,430.27 $6,747.35 0.8048 0.355218 0.00%1401006 SHEEHAN MEMORIAL EMERGENCY $3,215.32 $4,945.13 $6,747.35 0.7329 0.000000 0.00%

11



2951001 NORTH SHORE UNIVERSITY HOSP1327000 NORTHERN DUTCHESS HOSPITAL5920000 NORTHERN WESTCHESTER HOSP7001008 NY COMMUNITY / BROOKLYN7002026 NY EYE AND EAR INFIRMARY7003010 NY MED CTR OF QUEENS7001021 NY METHODIST HOSP / BROOKLYN7002054 NY PRESBYTERIAN HOSPITAL7002054 NY PRESBYTERIAN HOSPITAL (ALLEN)7002054 NY PRESBYTERIAN HOSPITAL (PRESBY)7000025 NY WESTCHESTER SQUARE MED CTR4324000 NYACK HOSPITAL7002053 NYU HOSPITALS CENTER7002053 NYU HOSPITALS CENTER/HOSP FOR JOINT DIS0401001 OLEAN GENERAL HOSPITAL2601001 ONEIDA HEALTHCARE CENTER3523000 ORANGE REGIONAL MED CTR3702000 OSWEGO HOSPITAL0301001 OUR LADY OF LOURDES MEMORIAL5155000 PECONIC BAY MED CTR7003006 PENINSULA HOSPITAL CENTER5932000 PHELPS MEMORIAL HOSP2952005 PLAINVIEW HOSPITAL3950000 PUTNAM COMMUNITY HOSPITAL7003007 QUEENS HOSPITAL CENTER7004010 RICHMOND UNIV MED CTR2701003 ROCHESTER GENERAL HOSPITAL3201002 ROME HOSPITAL AND MURPHY4102002 SAMARITAN HOSPITAL OF TROY2201000 SAMARITAN MEDICAL CENTER4501000 SARATOGA HOSPITAL4102003 SETON HEALTH SYSTEMS1401006 SHEEHAN MEMORIAL EMERGENCY

(7) (8) (9) (10) (11) (12)



ADD‐ON





POOL SURCHARGE


WCNF SURCHARGES

$1,547.50 $1,506.99 $195.57 $261.20 9.63% 28.27%$0.00 $362.67 $97.95 $171.74 9.63% 28.27%$0.00 $467.25 $118.37 $261.20 9.63% 28.27%$0.00 $226.07 $36.12 $261.20 9.63% 28.27%

$2,807.75 $310.18 $147.12 $261.20 9.63% 28.27%$1,054.11 $895.63 $133.48 $261.20 9.63% 28.27%$1,092.44 $385.19 $81.17 $261.20 9.63% 28.27%$1,666.26 $1,695.15 $242.00 $261.20 9.63% 28.27%$1,666.26 $1,695.15 $242.00 $261.20 9.63% 28.27%$1,666.26 $1,695.15 $242.00 $261.20 9.63% 28.27%

$0.00 $170.34 $25.26 $261.20 9.63% 28.27%$0.00 $185.67 $45.27 $261.20 9.63% 28.27%

$1,976.51 $1,134.75 $241.57 $261.20 9.63% 28.27%$1,976.51 $1,134.75 $241.57 $261.20 9.63% 28.27%

$0.00 $346.80 $72.03 $171.74 9.63% 28.27%$1.12 $653.86 $137.86 $171.74 9.63% 28.27%$0.00 $300.40 $68.49 $171.74 9.63% 28.27%$0.00 $482.28 $114.73 $171.74 9.63% 28.27%$5.70 $249.12 $61.81 $171.74 9.63% 28.27%$0.00 $886.03 $214.17 $261.20 9.63% 28.27%

$508.10 $190.25 $25.27 $261.20 9.63% 28.27%$0.00 $615.71 $138.68 $261.20 9.63% 28.27%

$191.12 $348.90 $66.59 $261.20 9.63% 28.27%$0.00 $568.79 $126.09 $171.74 9.63% 28.27%

$1,305.98 $1,456.89 $127.85 $261.20 9.63% 28.27%$580.64 $655.07 $61.23 $261.20 9.63% 28.27%$254.16 $519.49 $107.04 $171.74 9.63% 28.27%$0.00 $250.96 $58.92 $171.74 9.63% 28.27%$0.00 $442.98 $75.07 $171.74 9.63% 28.27%$24.45 $297.54 $64.00 $171.74 9.63% 28.27%$0.00 $392.89 $76.45 $171.74 9.63% 28.27%$0.00 $244.81 $56.01 $171.74 9.63% 28.27%$0.00 $0.00 $0.00 $171.74 9.63% 28.27%

12


(1) (2) (3) (4) (5) (6)



c(33))




c(33))




INDIRECT MEDICAL

EDUCATION (IME) %


1401013 SISTERS OF CHARITY HOSPITAL $4,834.16 $5,813.13 $6,747.35 0.8265 0.475144 4.24%5904000 SOUND SHORE MEDICAL CENTER $5,841.62 $7,699.33 $6,747.35 1.0294 0.538128 10.85%2950001 SOUTH NASSAU COMMUNITIES $6,523.99 $6,721.32 $6,747.35 0.9632 0.288378 3.42%5126000 SOUTHAMPTON HOSPITAL $4,737.63 $7,094.37 $6,747.35 1.0076 0.412366 4.35%5154000 SOUTHSIDE HOSPITAL $5,617.47 $7,400.75 $6,747.35 1.0468 0.337697 4.78%3529000 ST ANTHONY COMMUNITY HOSP $3,903.76 $6,452.49 $6,747.35 0.9563 0.262404 0.00%7000014 ST BARNABAS HOSPITAL $9,286.77 $8,749.43 $6,747.35 1.0267 0.262966 26.30%5157003 ST CATHERINE OF SIENA $7,413.16 $7,165.14 $6,747.35 1.0579 0.266765 0.38%5149001 ST CHARLES HOSPITAL $5,457.67 $6,571.78 $6,747.35 0.9651 0.313916 0.92%3202002 ST ELIZABETH MEDICAL CENTER $8,697.65 $5,986.12 $6,747.35 0.8391 0.481391 5.73%1302000 ST FRANCIS HOSP / POUGH $8,942.19 $5,829.71 $6,747.35 0.8640 0.318707 0.00%2953000 ST FRANCIS HOSP / ROSLYN $17,021.71 $7,227.37 $6,747.35 1.0656 0.332146 0.52%5002001 ST JAMES MERCY HOSPITAL $2,542.65 $4,460.00 $6,747.35 0.6610 0.501685 0.00%7001024 ST JOHNS EPISCOPAL SO SHORE $9,511.46 $10,094.47 $6,747.35 1.1937 0.504795 25.33%5907001 ST JOHNS RIVERSIDE HOSPITAL $4,147.69 $6,548.30 $6,747.35 0.9705 0.423654 0.00%0701001 ST JOSEPHS HOSP / ELMIRA $4,113.85 $5,012.61 $6,747.35 0.7429 0.479156 0.00%3301003 ST JOSEPHS HOSP HLTH CTR $5,722.23 $6,288.08 $6,747.35 0.8836 0.459105 5.47%5907002 ST JOSEPHS HOSPITAL YONKERS $7,266.30 $7,071.36 $6,747.35 0.9703 0.582145 8.01%7002032 ST LUKES / ROOSEVELT HOSP $11,899.24 $10,232.59 $6,747.35 1.2181 0.331090 24.50%3522000 ST LUKES CORNWALL $5,016.55 $6,179.53 $6,747.35 0.9024 0.241413 1.49%2801001 ST MARYS HOSP / AMSTERDAM $3,223.66 $5,098.30 $6,747.35 0.7556 0.518524 0.00%0101004 ST PETERS HOSPITAL $5,865.79 $5,980.99 $6,747.35 0.8670 0.349021 2.24%7002037 ST VINCENTS HOSPITAL / NYC $13,196.39 $8,916.64 $6,747.35 1.0245 0.300336 28.99%7001037 STATE UNIV HOSP / DOWNSTATE $13,906.31 $9,241.33 $6,747.35 1.0909 0.743965 25.55%7004003 STATEN ISLAND UNIV HOSP $10,423.82 $8,054.83 $6,747.35 1.0178 0.350479 17.29%2701005 STRONG MEMORIAL HOSPITAL $14,758.35 $7,831.41 $6,747.35 0.8996 0.571813 29.02%2754001 THE UNITY HOSPITAL $5,028.73 $5,630.69 $6,747.35 0.7752 0.563002 7.65%0427000 TLC HEALTH NETWORK $3,963.92 $4,604.39 $6,747.35 0.6824 0.594185 0.00%1227001 TRI‐TOWN REGIONAL HEALTHCARE $6,747.35 $6,747.35 $6,747.35 1.0000 1.000000 0.00%0303001 UNITED HEALTH SERVICES INC $6,851.15 $6,155.50 $6,747.35 0.8484 0.529650 7.53%1801000 UNITED MEMORIAL MED CTR $3,457.51 $5,159.70 $6,747.35 0.7647 0.513022 0.00%5151001 UNIV HOSP AT STONY BROOK $13,277.71 $8,909.09 $6,747.35 1.0257 0.433128 28.73%3301007 UNIV HOSP SUNY HLTH SCI CTR $15,530.04 $7,974.79 $6,747.35 0.9160 0.577036 29.03%

13



1401013 SISTERS OF CHARITY HOSPITAL5904000 SOUND SHORE MEDICAL CENTER2950001 SOUTH NASSAU COMMUNITIES5126000 SOUTHAMPTON HOSPITAL5154000 SOUTHSIDE HOSPITAL3529000 ST ANTHONY COMMUNITY HOSP7000014 ST BARNABAS HOSPITAL5157003 ST CATHERINE OF SIENA5149001 ST CHARLES HOSPITAL3202002 ST ELIZABETH MEDICAL CENTER1302000 ST FRANCIS HOSP / POUGH2953000 ST FRANCIS HOSP / ROSLYN5002001 ST JAMES MERCY HOSPITAL7001024 ST JOHNS EPISCOPAL SO SHORE5907001 ST JOHNS RIVERSIDE HOSPITAL0701001 ST JOSEPHS HOSP / ELMIRA3301003 ST JOSEPHS HOSP HLTH CTR5907002 ST JOSEPHS HOSPITAL YONKERS7002032 ST LUKES / ROOSEVELT HOSP3522000 ST LUKES CORNWALL2801001 ST MARYS HOSP / AMSTERDAM0101004 ST PETERS HOSPITAL7002037 ST VINCENTS HOSPITAL / NYC7001037 STATE UNIV HOSP / DOWNSTATE7004003 STATEN ISLAND UNIV HOSP2701005 STRONG MEMORIAL HOSPITAL2754001 THE UNITY HOSPITAL0427000 TLC HEALTH NETWORK1227001 TRI‐TOWN REGIONAL HEALTHCARE0303001 UNITED HEALTH SERVICES INC1801000 UNITED MEMORIAL MED CTR5151001 UNIV HOSP AT STONY BROOK3301007 UNIV HOSP SUNY HLTH SCI CTR

(7) (8) (9) (10) (11) (12)



ADD‐ON





POOL SURCHARGE


WCNF SURCHARGES

$154.59 $373.18 $68.07 $171.74 9.63% 28.27%$669.21 $283.59 $60.26 $261.20 9.63% 28.27%$135.37 $552.44 $107.27 $261.20 9.63% 28.27%$0.00 $583.69 $166.05 $261.20 9.63% 28.27%

$173.48 $549.48 $125.40 $261.20 9.63% 28.27%$0.00 $298.01 $72.75 $171.74 9.63% 28.27%

$1,266.16 $456.65 $97.81 $261.20 9.63% 28.27%$61.72 $376.63 $68.80 $261.20 9.63% 28.27%$101.67 $445.08 $106.09 $261.20 9.63% 28.27%$129.72 $605.90 $88.69 $171.74 9.63% 28.27%$0.00 $765.96 $159.75 $171.74 9.63% 28.27%

$220.24 $845.06 $145.20 $261.20 9.63% 28.27%$0.00 $303.84 $92.38 $171.74 9.63% 28.27%

$902.89 $276.11 $43.68 $261.20 9.63% 28.27%$0.00 $419.21 $63.71 $261.20 9.63% 28.27%$0.00 $202.49 $39.41 $171.74 9.63% 28.27%$49.76 $547.77 $89.46 $171.74 9.63% 28.27%$281.21 $373.34 $69.68 $261.20 9.63% 28.27%

$1,445.62 $891.04 $169.31 $261.20 9.63% 28.27%$0.00 $337.56 $74.26 $171.74 9.63% 28.27%$0.00 $186.50 $38.98 $171.74 9.63% 28.27%$72.61 $537.80 $112.00 $171.74 9.63% 28.27%

$1,736.72 $831.19 $108.89 $261.20 9.63% 28.27%$2,355.57 $731.69 $127.21 $261.20 9.63% 28.27%$718.55 $414.71 $60.23 $261.20 9.63% 28.27%$869.35 $681.23 $114.53 $171.74 9.63% 28.27%$51.77 $463.11 $99.61 $171.74 9.63% 28.27%$0.00 $117.31 $28.87 $171.74 9.63% 28.27%$0.00 $253.00 $126.50 $171.74 9.63% 28.27%

$231.53 $327.16 $65.74 $171.74 9.63% 28.27%$0.00 $275.62 $63.67 $171.74 9.63% 28.27%

$1,291.42 $1,176.51 $184.89 $261.20 9.63% 28.27%$1,358.84 $744.18 $133.72 $171.74 9.63% 28.27%

14


(1) (2) (3) (4) (5) (6)



c(33))




c(33))




INDIRECT MEDICAL

EDUCATION (IME) %


1302001 VASSAR BROTHERS MED CTR $5,930.12 $6,695.40 $6,747.35 0.9923 0.307627 0.00%5820000 WAYNE HEALTH CARE $2,781.41 $5,218.40 $6,747.35 0.7734 0.485046 0.00%5957001 WESTCHESTER MEDICAL CENTER $17,952.89 $9,112.48 $6,747.35 1.1393 0.342782 18.54%0632000 WESTFIELD MEMORIAL HOSP $2,516.20 $4,854.72 $6,747.35 0.7195 0.884032 0.00%5902001 WHITE PLAINS HOSPITAL $6,277.78 $6,903.21 $6,747.35 1.0231 0.460502 0.00%2908000 WINTHROP UNIVERSITY HOSPITAL $8,388.42 $7,667.30 $6,747.35 0.9754 0.300934 16.50%0602001 WOMANS CHRISTIAN ASSOC $3,460.65 $5,003.83 $6,747.35 0.7416 0.469819 0.00%7001045 WOODHULL MEDICAL $10,303.85 $8,287.95 $6,747.35 1.0175 0.933577 20.72%7001035 WYCKOFF HEIGHTS HOSPITAL $8,894.76 $8,350.33 $6,747.35 1.0677 0.509478 15.91%6027000 WYOMING CO COMMUNITY HOSP $2,824.95 $5,235.27 $6,747.35 0.7759 0.942083 0.00%

*Maimonides' Capital per Discharge rate includes a High Cost Outlier add‐on of $900.81

15



1302001 VASSAR BROTHERS MED CTR5820000 WAYNE HEALTH CARE5957001 WESTCHESTER MEDICAL CENTER0632000 WESTFIELD MEMORIAL HOSP5902001 WHITE PLAINS HOSPITAL2908000 WINTHROP UNIVERSITY HOSPITAL0602001 WOMANS CHRISTIAN ASSOC7001045 WOODHULL MEDICAL7001035 WYCKOFF HEIGHTS HOSPITAL6027000 WYOMING CO COMMUNITY HOSP

(7) (8) (9) (10) (11) (12)



ADD‐ON





POOL SURCHARGE


WCNF SURCHARGES

$0.00 $529.42 $109.25 $171.74 9.63% 28.27%$0.00 $296.69 $66.15 $171.74 9.63% 28.27%

$2,153.68 $1,700.47 $237.43 $261.20 9.63% 28.27%$0.00 $726.45 $242.15 $171.74 9.63% 28.27%$0.00 $456.13 $85.21 $261.20 9.63% 28.27%

$821.57 $679.76 $136.92 $261.20 9.63% 28.27%$0.00 $170.35 $38.80 $171.74 9.63% 28.27%

$2,392.18 $3,333.11 $129.55 $261.20 9.63% 28.27%$1,185.74 $560.78 $109.37 $261.20 9.63% 28.27%

$0.00 $142.78 $30.21 $171.74 9.63% 28.27%

16

SCHEDULE OF WORKER'S COMP/NO FAULT (WCNF) INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/10 - 3/31/10

(1) (2) (3) (4) (5) (6) (7) (8)

SPECIALTY ACUTE, LONG‐TERM CARE AND CHILDREN'S HOSPITAL BILLING

RATE

SPECIALTY ACUTE, LONG‐TERM CARE AND CHILDREN'S

HOSPITAL ALC PER DIEM

PSYCHIATRIC BILLING RATE

PSYCHIATRIC ALC PER DIEM

CHEMICAL DEPENDENCY REHAB BILLING

RATE

CHEMICAL DEPENDENCY

REHAB ALC PER DIEM

CRITICAL ACCESS HOSPITAL

BILLING RATE


ALC PER DIEM

OPCERT HOSPITAL NAME1623001 ADIRONDACK MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000101005 ALB MED CTR SO CLINICAL CAMP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000101000 ALBANY MEDICAL CTR HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003701000 ALBERT LINDLEY LEE MEM HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001624000 ALICE HYDE MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000701000 ARNOT OGDEN MEDICAL CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000501000 AUBURN MEMORIAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003801000 AURELIA OSBORN FOX MEM HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002001 BELLEVUE HOSPITAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005501000 BENEDICTINE HOSPITAL $0.00 $0.00 TBD TBD $306.30 $171.74 $0.00 $0.001427000 BERTRAND CHAFFEE HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001041 BETH ISRAEL / KINGS HIGHWAY $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002002 BETH ISRAEL MEDICAL CENTER $0.00 $0.00 TBD TBD $674.51 $261.20 $0.00 $0.005957000 BLYTHEDALE CHILDRENS HOSP $1,534.29 $261.20 TBD TBD $0.00 $0.00 $0.00 $0.003535001 BON SECOURS COMMUNITY HOSP $0.00 $0.00 TBD TBD $524.72 $171.74 $0.00 $0.007000001 BRONX‐LEBANON HOSPITAL CTR $0.00 $0.00 TBD TBD $641.89 $261.20 $0.00 $0.007001002 BROOKDALE HOSPITAL MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005123000 BROOKHAVEN MEMORIAL HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001003 BROOKLYN HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000601000 BROOKS MEMORIAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005902002 BURKE REHABILITATION CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007000011 CALVARY HOSPITAL $1,054.96 $261.20 TBD TBD $0.00 $0.00 $0.00 $0.004429000 CANTON‐POTSDAM HOSPITAL $0.00 $0.00 TBD TBD $421.17 $171.74 $0.00 $0.002238001 CARTHAGE AREA HOSPITAL INC $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005263700 CATSKILL REGIONAL / G HERMANN $0.00 $0.00 TBD TBD $0.00 $0.00 $2,429.80 $171.745263000 CATSKILL REGIONAL MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005401001 CAYUGA MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000901001 CHAMPLAIN VALLEY PHYS $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000824000 CHENANGO MEMORIAL HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.004401000 CLAXTON‐HEPBURN MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003421000 CLIFTON SPRINGS HOSPITAL $0.00 $0.00 TBD TBD $287.58 $171.74 $0.00 $0.004458700 CLIFTON‐FINE HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $2,308.66 $171.744720001 COBLESKILL REGIONAL HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002051 COLER MEMORIAL HOSP $639.66 $261.20 TBD TBD $0.00 $0.00 $0.00 $0.001001000 COLUMBIA MEMORIAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.00

SPECIALTY PSYCHIATRIC CHEMICAL DEPENDENCY REHAB CRITICAL ACCESS

17


OPCERT HOSPITAL NAME1623001 ADIRONDACK MEDICAL CENTER0101005 ALB MED CTR SO CLINICAL CAMP0101000 ALBANY MEDICAL CTR HOSP3701000 ALBERT LINDLEY LEE MEM HOSP1624000 ALICE HYDE MEDICAL CENTER0701000 ARNOT OGDEN MEDICAL CTR0501000 AUBURN MEMORIAL HOSPITAL3801000 AURELIA OSBORN FOX MEM HOSP7002001 BELLEVUE HOSPITAL CENTER5501000 BENEDICTINE HOSPITAL1427000 BERTRAND CHAFFEE HOSPITAL7001041 BETH ISRAEL / KINGS HIGHWAY7002002 BETH ISRAEL MEDICAL CENTER5957000 BLYTHEDALE CHILDRENS HOSP3535001 BON SECOURS COMMUNITY HOSP7000001 BRONX‐LEBANON HOSPITAL CTR7001002 BROOKDALE HOSPITAL MED CTR5123000 BROOKHAVEN MEMORIAL HOSP7001003 BROOKLYN HOSPITAL0601000 BROOKS MEMORIAL HOSPITAL5902002 BURKE REHABILITATION CTR7000011 CALVARY HOSPITAL4429000 CANTON‐POTSDAM HOSPITAL2238001 CARTHAGE AREA HOSPITAL INC5263700 CATSKILL REGIONAL / G HERMANN5263000 CATSKILL REGIONAL MED CTR5401001 CAYUGA MEDICAL CENTER0901001 CHAMPLAIN VALLEY PHYS0824000 CHENANGO MEMORIAL HOSP4401000 CLAXTON‐HEPBURN MED CTR3421000 CLIFTON SPRINGS HOSPITAL4458700 CLIFTON‐FINE HOSPITAL4720001 COBLESKILL REGIONAL HOSP7002051 COLER MEMORIAL HOSP1001000 COLUMBIA MEMORIAL HOSPITAL

(9) (10) (11) (12) (13) (14)

MEDICAL REHAB BILLING RATE

MEDICAL REHAB ALC PER DIEM

DETOX ‐ MEDICALLY MANAGED

WITHDRAWAL BILLING RATE

DETOX ‐ MEDICALLY SUPERVISED WITHDRAWAL BILLING RATE

WCNF PUBLIC GOODS POOL SURCHARGE

WCNF ADDITIONAL

PUBLIC GOODS POOL

SURCHARGE

$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$998.41 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$1,158.03 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$952.44 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$1,432.42 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$1,303.64 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$1,105.85 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%


$966.89 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%


WCNF SURCHARGESMEDICAL REHABILITATION DETOX

18


(1) (2) (3) (4) (5) (6) (7) (8)


RATE






RATE

CHEMICAL DEPENDENCY

REHAB ALC PER DIEM


BILLING RATE


ALC PER DIEM



3301000 COMM‐GEN / GREATER SYRACUSE $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002625000 COMMUNITY MEMORIAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001009 CONEY ISLAND HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005001000 CORNING HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001101000 CORTLAND REGIONAL MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003301008 CROUSE HOSPITAL $0.00 $0.00 TBD TBD $415.46 $171.74 $0.00 $0.000226700 CUBA MEMORIAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $2,322.48 $171.741229700 DELAWARE VALLEY HOSPITAL $0.00 $0.00 TBD TBD $1,058.92 $171.74 $1,058.92 $171.744423000 E J NOBLE HOSP / GOUVERNEUR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005127000 EASTERN LONG ISLAND HOSPITAL $0.00 $0.00 TBD TBD $638.56 $261.20 $0.00 $0.003101000 EASTERN NIAGARA HOSPITAL $0.00 $0.00 TBD TBD $295.29 $171.74 $0.00 $0.001552701 ELIZABETHTOWN COMMUNITY HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $1,990.91 $171.745526700 ELLENVILLE REGIONAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $1,773.67 $171.744601001 ELLIS HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007003000 ELMHURST HOSPITAL CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001401005 ERIE COUNTY MEDICAL CENTER $0.00 $0.00 TBD TBD $271.98 $171.74 $0.00 $0.003429000 F F THOMPSON HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003202003 FAXTON‐ST LUKES HEALTHCARE $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007003001 FLUSHING HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007003013 FOREST HILLS HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002910000 FRANKLIN HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003402000 GENEVA GENERAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002901000 GLEN COVE HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005601000 GLENS FALLS HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002050 GOLDWATER MEMORIAL HOSP $695.56 $261.20 TBD TBD $0.00 $0.00 $0.00 $0.004329000 GOOD SAMARITAN / SUFFERN $0.00 $0.00 TBD TBD $537.32 $261.20 $0.00 $0.005154001 GOOD SAMARITAN / WEST ISLIP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002009 HARLEM HOSPITAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.004322000 HELEN HAYES HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002701001 HIGHLAND HOSP OF ROCHESTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002012 HOSPITAL FOR SPECIAL SURGERY $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005901000 HUDSON VALLEY HOSPITAL CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005153000 HUNTINGTON HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001046 INTERFAITH MEDICAL CENTER $0.00 $0.00 TBD TBD $523.23 $261.20 $0.00 $0.005022000 IRA DAVENPORT MEMORIAL HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.00

19


OPCERT HOSPITAL NAME3301000 COMM‐GEN / GREATER SYRACUSE2625000 COMMUNITY MEMORIAL HOSPITAL7001009 CONEY ISLAND HOSPITAL5001000 CORNING HOSPITAL1101000 CORTLAND REGIONAL MED CTR3301008 CROUSE HOSPITAL0226700 CUBA MEMORIAL HOSPITAL1229700 DELAWARE VALLEY HOSPITAL4423000 E J NOBLE HOSP / GOUVERNEUR5127000 EASTERN LONG ISLAND HOSPITAL3101000 EASTERN NIAGARA HOSPITAL1552701 ELIZABETHTOWN COMMUNITY HOSP5526700 ELLENVILLE REGIONAL HOSPITAL4601001 ELLIS HOSPITAL7003000 ELMHURST HOSPITAL CTR1401005 ERIE COUNTY MEDICAL CENTER3429000 F F THOMPSON HOSPITAL3202003 FAXTON‐ST LUKES HEALTHCARE7003001 FLUSHING HOSPITAL7003013 FOREST HILLS HOSPITAL2910000 FRANKLIN HOSPITAL3402000 GENEVA GENERAL HOSPITAL2901000 GLEN COVE HOSPITAL5601000 GLENS FALLS HOSPITAL7002050 GOLDWATER MEMORIAL HOSP4329000 GOOD SAMARITAN / SUFFERN5154001 GOOD SAMARITAN / WEST ISLIP7002009 HARLEM HOSPITAL CENTER4322000 HELEN HAYES HOSPITAL2701001 HIGHLAND HOSP OF ROCHESTER7002012 HOSPITAL FOR SPECIAL SURGERY5901000 HUDSON VALLEY HOSPITAL CTR5153000 HUNTINGTON HOSPITAL7001046 INTERFAITH MEDICAL CENTER5022000 IRA DAVENPORT MEMORIAL HOSP

(9) (10) (11) (12) (13) (14)







WCNF ADDITIONAL

PUBLIC GOODS POOL

SURCHARGE



$1,106.46 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$1,406.12 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,056.85 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$905.68 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$1,148.86 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,097.49 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,079.07 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%




20


(1) (2) (3) (4) (5) (6) (7) (8)


RATE






RATE

CHEMICAL DEPENDENCY

REHAB ALC PER DIEM


BILLING RATE


ALC PER DIEM



7000002 JACOBI MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007003003 JAMAICA HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005149000 JOHN T MATHER MEMORIAL HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000228000 JONES MEMORIAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001401014 KALEIDA HEALTH $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001401002 KALEIDA HLTH/WOMAN&CHILDRENS $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001404000 KENMORE MERCY HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001016 KINGS COUNTY HOSPITAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001033 KINGSBROOK JEWISH MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005501001 KINGSTON HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002728001 LAKESIDE MEMORIAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005922000 LAWRENCE HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002017 LENOX HILL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002424000 LEWIS COUNTY GENERAL HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007000008 LINCOLN MEDICAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002129700 LITTLE FALLS HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $1,462.06 $171.742902000 LONG BEACH MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001017 LONG ISLAND COLLEGE HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007003004 LONG ISLAND JEWISH $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001019 LUTHERAN MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001020 MAIMONIDES MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001226701 MARGARETVILLE HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $1,900.56 $171.743824000 MARY IMOGENE BASSETT HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.004402000 MASSENA MEMORIAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003622000 MEDINA MEMORIAL HLTH CARE $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002020 MEMORIAL HOSP FOR CANCER $3,063.73 $261.20 TBD TBD $0.00 $0.00 $0.00 $0.000101003 MEMORIAL HOSP OF ALBANY $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001401008 MERCY HOSPITAL OF BUFFALO $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002909000 MERCY MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002021 METROPOLITAN HOSPITAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002701006 MONROE COMMUNITY HOSPITAL $2,495.17 $171.74 TBD TBD $0.00 $0.00 $0.00 $0.007000006 MONTEFIORE MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001564701 MOSES‐LUDINGTON HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $2,456.79 $171.747003015 MOUNT SINAI HOSP OF QUEENS $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002024 MOUNT SINAI HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.00

21


OPCERT HOSPITAL NAME7000002 JACOBI MEDICAL CENTER7003003 JAMAICA HOSPITAL5149000 JOHN T MATHER MEMORIAL HOSP0228000 JONES MEMORIAL HOSPITAL1401014 KALEIDA HEALTH1401002 KALEIDA HLTH/WOMAN&CHILDRENS1404000 KENMORE MERCY HOSPITAL7001016 KINGS COUNTY HOSPITAL CENTER7001033 KINGSBROOK JEWISH MED CTR5501001 KINGSTON HOSPITAL2728001 LAKESIDE MEMORIAL HOSPITAL5922000 LAWRENCE HOSPITAL7002017 LENOX HILL HOSPITAL2424000 LEWIS COUNTY GENERAL HOSP7000008 LINCOLN MEDICAL2129700 LITTLE FALLS HOSPITAL2902000 LONG BEACH MEDICAL CENTER7001017 LONG ISLAND COLLEGE HOSPITAL7003004 LONG ISLAND JEWISH7001019 LUTHERAN MEDICAL CENTER7001020 MAIMONIDES MEDICAL CENTER1226701 MARGARETVILLE HOSPITAL3824000 MARY IMOGENE BASSETT HOSP4402000 MASSENA MEMORIAL HOSPITAL3622000 MEDINA MEMORIAL HLTH CARE7002020 MEMORIAL HOSP FOR CANCER0101003 MEMORIAL HOSP OF ALBANY1401008 MERCY HOSPITAL OF BUFFALO2909000 MERCY MEDICAL CENTER7002021 METROPOLITAN HOSPITAL CENTER2701006 MONROE COMMUNITY HOSPITAL7000006 MONTEFIORE MEDICAL CENTER1564701 MOSES‐LUDINGTON HOSPITAL7003015 MOUNT SINAI HOSP OF QUEENS7002024 MOUNT SINAI HOSPITAL

(9) (10) (11) (12) (13) (14)







WCNF ADDITIONAL

PUBLIC GOODS POOL

SURCHARGE





$725.34 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,833.56 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,064.20 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$831.00 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$664.33 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,648.81 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%






$1,350.82 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

22


(1) (2) (3) (4) (5) (6) (7) (8)


RATE






RATE

CHEMICAL DEPENDENCY

REHAB ALC PER DIEM


BILLING RATE


ALC PER DIEM



3121001 MOUNT ST MARYS HOSPITAL $0.00 $0.00 TBD TBD $339.63 $171.74 $0.00 $0.005903000 MOUNT VERNON HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002950002 NASSAU UNIV MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001701000 NATHAN LITTAUER HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002952006 NEW ISLAND HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002000 NEW YORK DOWNTOWN HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003102000 NIAGARA FALLS MEMORIAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002527000 NICHOLAS H NOYES MEMORIAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007000024 NORTH CENTRAL BRONX HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002052 NORTH GENERAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002951001 NORTH SHORE UNIVERSITY HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001327000 NORTHERN DUTCHESS HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005920000 NORTHERN WESTCHESTER HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001008 NY COMMUNITY / BROOKLYN $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002026 NY EYE AND EAR INFIRMARY $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007003010 NY MED CTR OF QUEENS $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001021 NY METHODIST HOSP / BROOKLYN $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002054 NY PRESBYTERIAN HOSPITAL $0.00 $0.00 TBD TBD $679.82 $261.20 $0.00 $0.007002054 NY PRESBYTERIAN HOSPITAL (PRESBY) $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007000025 NY WESTCHESTER SQUARE MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.004324000 NYACK HOSPITAL $0.00 $0.00 TBD TBD $427.38 $261.20 $0.00 $0.007002053 NYU HOSPITALS CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002053 NYU HOSPITALS CENTER/HOSP FOR JOINT D $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001254700 O'CONNOR HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $2,326.73 $171.740401001 OLEAN GENERAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002601001 ONEIDA HEALTHCARE CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003523000 ORANGE REGIONAL MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003702000 OSWEGO HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000301001 OUR LADY OF LOURDES MEMORIAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005155000 PECONIC BAY MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007003006 PENINSULA HOSPITAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005932000 PHELPS MEMORIAL HOSP $0.00 $0.00 TBD TBD $566.97 $261.20 $0.00 $0.002952005 PLAINVIEW HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003950000 PUTNAM COMMUNITY HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007003007 QUEENS HOSPITAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.00

23


OPCERT HOSPITAL NAME3121001 MOUNT ST MARYS HOSPITAL5903000 MOUNT VERNON HOSPITAL2950002 NASSAU UNIV MED CTR1701000 NATHAN LITTAUER HOSPITAL2952006 NEW ISLAND HOSPITAL7002000 NEW YORK DOWNTOWN HOSP3102000 NIAGARA FALLS MEMORIAL2527000 NICHOLAS H NOYES MEMORIAL7000024 NORTH CENTRAL BRONX HOSPITAL7002052 NORTH GENERAL HOSPITAL2951001 NORTH SHORE UNIVERSITY HOSP1327000 NORTHERN DUTCHESS HOSPITAL5920000 NORTHERN WESTCHESTER HOSP7001008 NY COMMUNITY / BROOKLYN7002026 NY EYE AND EAR INFIRMARY7003010 NY MED CTR OF QUEENS7001021 NY METHODIST HOSP / BROOKLYN7002054 NY PRESBYTERIAN HOSPITAL7002054 NY PRESBYTERIAN HOSPITAL (PRESBY)7000025 NY WESTCHESTER SQUARE MED CTR4324000 NYACK HOSPITAL7002053 NYU HOSPITALS CENTER7002053 NYU HOSPITALS CENTER/HOSP FOR JOINT D1254700 O'CONNOR HOSPITAL0401001 OLEAN GENERAL HOSPITAL2601001 ONEIDA HEALTHCARE CENTER3523000 ORANGE REGIONAL MED CTR3702000 OSWEGO HOSPITAL0301001 OUR LADY OF LOURDES MEMORIAL5155000 PECONIC BAY MED CTR7003006 PENINSULA HOSPITAL CENTER5932000 PHELPS MEMORIAL HOSP2952005 PLAINVIEW HOSPITAL3950000 PUTNAM COMMUNITY HOSPITAL7003007 QUEENS HOSPITAL CENTER

(9) (10) (11) (12) (13) (14)







WCNF ADDITIONAL

PUBLIC GOODS POOL

SURCHARGE



$1,267.74 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$1,229.19 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

$889.68 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,510.56 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,510.56 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%




$971.04 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%



$1,509.69 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

24


(1) (2) (3) (4) (5) (6) (7) (8)


RATE






RATE

CHEMICAL DEPENDENCY

REHAB ALC PER DIEM


BILLING RATE


ALC PER DIEM



7004010 RICHMOND UNIV MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002221700 RIVER HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $2,307.66 $171.742701003 ROCHESTER GENERAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002031 ROCKEFELLER UNIVERSITY $2,255.76 $261.20 TBD TBD $0.00 $0.00 $0.00 $0.003201002 ROME HOSPITAL AND MURPHY $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001401010 ROSWELL PARK $2,578.69 $171.74 TBD TBD $0.00 $0.00 $0.00 $0.004102002 SAMARITAN HOSPITAL OF TROY $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002201000 SAMARITAN MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.004501000 SARATOGA HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.004823700 SCHUYLER HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $1,386.31 $171.744102003 SETON HEALTH SYSTEMS $0.00 $0.00 TBD TBD $192.22 $171.74 $0.00 $0.001401006 SHEEHAN MEMORIAL EMERGENCY $0.00 $0.00 TBD TBD $276.66 $171.74 $0.00 $0.001401013 SISTERS OF CHARITY HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.006120700 SOLDIERS AND SAILORS MEM HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $1,728.02 $171.745904000 SOUND SHORE MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002950001 SOUTH NASSAU COMMUNITIES $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005126000 SOUTHAMPTON HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005154000 SOUTHSIDE HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003529000 ST ANTHONY COMMUNITY HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007000014 ST BARNABAS HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005157003 ST CATHERINE OF SIENA $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005149001 ST CHARLES HOSPITAL $0.00 $0.00 TBD TBD $246.86 $261.20 $0.00 $0.003202002 ST ELIZABETH MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001302000 ST FRANCIS HOSP / POUGH $0.00 $0.00 TBD TBD $322.85 $171.74 $0.00 $0.002953000 ST FRANCIS HOSP / ROSLYN $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005002001 ST JAMES MERCY HOSPITAL $0.00 $0.00 TBD TBD $312.70 $171.74 $0.00 $0.007001024 ST JOHNS EPISCOPAL SO SHORE $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005907001 ST JOHNS RIVERSIDE HOSPITAL $0.00 $0.00 TBD TBD $473.44 $261.20 $0.00 $0.000701001 ST JOSEPHS HOSP / ELMIRA $0.00 $0.00 TBD TBD $306.13 $171.74 $0.00 $0.003301003 ST JOSEPHS HOSP HLTH CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005907002 ST JOSEPHS HOSPITAL YONKERS $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002032 ST LUKES / ROOSEVELT HOSP $0.00 $0.00 TBD TBD $531.81 $261.20 $0.00 $0.003522000 ST LUKES CORNWALL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002801001 ST MARYS HOSP / AMSTERDAM $0.00 $0.00 TBD TBD $378.81 $171.74 $0.00 $0.002801001 ST MARYS HOSP / AMSTERDAM MEM CAMP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.00

25


OPCERT HOSPITAL NAME7004010 RICHMOND UNIV MED CTR2221700 RIVER HOSPITAL2701003 ROCHESTER GENERAL HOSPITAL7002031 ROCKEFELLER UNIVERSITY3201002 ROME HOSPITAL AND MURPHY1401010 ROSWELL PARK 4102002 SAMARITAN HOSPITAL OF TROY2201000 SAMARITAN MEDICAL CENTER4501000 SARATOGA HOSPITAL4823700 SCHUYLER HOSPITAL4102003 SETON HEALTH SYSTEMS1401006 SHEEHAN MEMORIAL EMERGENCY1401013 SISTERS OF CHARITY HOSPITAL6120700 SOLDIERS AND SAILORS MEM HOSP5904000 SOUND SHORE MEDICAL CENTER2950001 SOUTH NASSAU COMMUNITIES5126000 SOUTHAMPTON HOSPITAL5154000 SOUTHSIDE HOSPITAL3529000 ST ANTHONY COMMUNITY HOSP7000014 ST BARNABAS HOSPITAL5157003 ST CATHERINE OF SIENA5149001 ST CHARLES HOSPITAL3202002 ST ELIZABETH MEDICAL CENTER1302000 ST FRANCIS HOSP / POUGH2953000 ST FRANCIS HOSP / ROSLYN5002001 ST JAMES MERCY HOSPITAL7001024 ST JOHNS EPISCOPAL SO SHORE5907001 ST JOHNS RIVERSIDE HOSPITAL0701001 ST JOSEPHS HOSP / ELMIRA3301003 ST JOSEPHS HOSP HLTH CTR5907002 ST JOSEPHS HOSPITAL YONKERS7002032 ST LUKES / ROOSEVELT HOSP3522000 ST LUKES CORNWALL2801001 ST MARYS HOSP / AMSTERDAM2801001 ST MARYS HOSP / AMSTERDAM MEM CAMP

(9) (10) (11) (12) (13) (14)







WCNF ADDITIONAL

PUBLIC GOODS POOL

SURCHARGE





$1,118.28 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%



$1,185.97 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%



$999.70 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

26


(1) (2) (3) (4) (5) (6) (7) (8)


RATE






RATE

CHEMICAL DEPENDENCY

REHAB ALC PER DIEM


BILLING RATE


ALC PER DIEM



0101004 ST PETERS HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007002037 ST VINCENTS HOSPITAL / NYC $0.00 $0.00 TBD TBD $386.69 $261.20 $0.00 $0.007001037 STATE UNIV HOSP / DOWNSTATE $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007004003 STATEN ISLAND UNIV HOSP $0.00 $0.00 TBD TBD $538.40 $261.20 $0.00 $0.002701005 STRONG MEMORIAL HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.004353000 SUMMIT PARK HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.004601004 SUNNYVIEW HOSP AND REHAB $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002754001 THE UNITY HOSPITAL $0.00 $0.00 TBD TBD $367.35 $171.74 $0.00 $0.000427000 TLC HEALTH NETWORK $0.00 $0.00 TBD TBD $194.88 $171.74 $0.00 $0.001227001 TRI‐TOWN REGIONAL HEALTHCARE $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000303001 UNITED HEALTH SERVICES INC $0.00 $0.00 TBD TBD $482.02 $171.74 $0.00 $0.001801000 UNITED MEMORIAL MED CTR $0.00 $0.00 TBD TBD $334.16 $171.74 $0.00 $0.005151001 UNIV HOSP AT STONY BROOK $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.003301007 UNIV HOSP SUNY HLTH SCI CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.001302001 VASSAR BROTHERS MED CTR $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005820000 WAYNE HEALTH CARE $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005957001 WESTCHESTER MEDICAL CENTER $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000632000 WESTFIELD MEMORIAL HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.005902001 WHITE PLAINS HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.002908000 WINTHROP UNIVERSITY HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.000602001 WOMANS CHRISTIAN ASSOC $0.00 $0.00 TBD TBD $337.95 $171.74 $0.00 $0.007001045 WOODHULL MEDICAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.007001035 WYCKOFF HEIGHTS HOSPITAL $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.006027000 WYOMING CO COMMUNITY HOSP $0.00 $0.00 TBD TBD $0.00 $0.00 $0.00 $0.00

27


OPCERT HOSPITAL NAME0101004 ST PETERS HOSPITAL7002037 ST VINCENTS HOSPITAL / NYC7001037 STATE UNIV HOSP / DOWNSTATE7004003 STATEN ISLAND UNIV HOSP2701005 STRONG MEMORIAL HOSPITAL4353000 SUMMIT PARK HOSPITAL4601004 SUNNYVIEW HOSP AND REHAB2754001 THE UNITY HOSPITAL0427000 TLC HEALTH NETWORK1227001 TRI‐TOWN REGIONAL HEALTHCARE0303001 UNITED HEALTH SERVICES INC1801000 UNITED MEMORIAL MED CTR5151001 UNIV HOSP AT STONY BROOK3301007 UNIV HOSP SUNY HLTH SCI CTR1302001 VASSAR BROTHERS MED CTR5820000 WAYNE HEALTH CARE5957001 WESTCHESTER MEDICAL CENTER0632000 WESTFIELD MEMORIAL HOSP5902001 WHITE PLAINS HOSPITAL2908000 WINTHROP UNIVERSITY HOSPITAL0602001 WOMANS CHRISTIAN ASSOC7001045 WOODHULL MEDICAL7001035 WYCKOFF HEIGHTS HOSPITAL6027000 WYOMING CO COMMUNITY HOSP

(9) (10) (11) (12) (13) (14)







WCNF ADDITIONAL

PUBLIC GOODS POOL

SURCHARGE



$1,758.65 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,278.46 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$1,153.22 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$924.18 $261.20 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$936.96 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%





$853.28 $171.74 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%$0.00 $0.00 FOR FUTURE USE FOR FUTURE USE 9.63% 28.27%

28

Sample PaymentCalculation Worksheet

WORKER'S COMP - NO FAULTINLIER PAYMENT

Line Calculation Elements

Worker's Compensation, No Fault, Volunteer

Firefighters, Volunteer Ambulance Workers

Data Source and Formulas

(1) Discharge Case Payment Rate PUB_IP_WCNF_Acute_Col 2

(2) Per Case Service Intensity Weight for DRG Classification SIW APR-DRG Table (DOH*)

(3) Case Mix Adjusted Discharge Payment Line 1 x Line 2

(4) Direct Medical Education (DME) Add-On PUB_IP_WCNF_Acute_Col 7

(5) Capital and Non-Comparable Add-Ons Cost Per Discharge PUB_IP_WCNF_Acute_Col 8

(6) Inlier DRG Payment prior to Public Goods Pool Surcharge Line 3 + Line 4 + Line 5

(7a) Public Goods Surcharge - Pay directly to Pool (see footnote for table of values) Line 6 x Surcharge %

(7b) Public Goods Surcharge - Pay to Hospital (see footnote for table of values) Line 6 x Surcharge %

(8a) Payment to Hospital - Surcharge paid Directly to pool Line 6

(8b) Payment to Hospital - Surcharge paid to Hospital (hospital pays pool) Line 6 + Line 7b


(9) Alternate Level of Care Operating Per Diem PUB_IP_WCNF_Acute_Col 10

(10) Number of Alternate Level of Care (ALC) Days Medical Record(11) Total ALC Payment Prior to Public Goods Pool Surcharge Line 9 x Line 10

(12a) Public Goods Surcharge - Pay directly to Pool (see footnotes for table of values) Line 11 x Surcharge %

(12b) Public Goods Surcharge - Pay to Hospital (see footnotes for table of values) Line 11 x Surcharge %



Footnotes: Pay Directly To PoolSurcharge April 1, 2009========> 9.63%

Pay To HospitalSurcharge April 1, 2009========> 9.63%&28.27%

* The SIW APR-DRG Table is available on the DOH public website at:http://www.nyhealth.gov/facilities/hospital/reimbursement/apr-drg/

INLIER PAYMENT:

ALTERNATE LEVEL OF CARE PAYMENT:

CALCULATION OF INLIER PAYMENT:

29


WORKER'S COMP - NO FAULTTRANSFER PAYMENT




Data Source and Formulas(1) Number of Transfer Days

a. Total Number of Days in Stay (inc. ALC) Medical Record

b. Alternate Level of Care (ALC) Days Medical Record

c. Number of Transfer Days excluding ALC Line 1a - 1b

(2) DRG Classification Assigned by Grouper

(3) Discharge Case Payment Rate PUB_IP_WCNF_Acute_Col 2

(4) Per Case Service Intensity Weight for DRG Classification

SIW APR-DRG Table (DOH*)

(5) Case Mix Adjusted Discharge Payment Line 3 x Line 4

(6) Group Average Arithmetic Inlier Length of Stay for DRG

SIW APR-DRG Table (DOH*)

(7) Average Inlier Cost Per Day Line 5 / Line 6

(8) Transfer Adjustment Factor a. If Transfer Days are = to 1 and the Group Average LOS = 1, then 100%

100%

b. If Transfer Days are = to or > 1 and the Group Average LOS is > 1 , then 120%

120%

(9) Transfer DRG Cost Per Day Line 7 x Line 8a or 8b

(10) Case Payment Capital Per Diem PUB_IP_WCNF_Acute_Col 9

(11) Total Transfer Cost Per Diem Line 9 + Line 10

(12) Transfer DRG Payment excluding DME Line 11 x Line 1c

(13) Direct Medical Education (DME) Add-on PUB_IP_WCNF_Acute_Col 7

(14) Transfer Payment Amount before ALC Line 12 + Line 13

(15) Discharge DRG Test (See Note 1 below):

(a) Inlier DRG Before ALC Inlier Tab, Line 6

(16) Total Transfer Payment Prior to Public Goods Pool Surcharge (and ALC)

Lesser of Line 14 or Line 15a



(18a) Payment to Hospital - Surcharge paid Directly to pool

Line 16

(18b) Payment to Hospital - Surcharge paid to Hospital (hospital pays pool)

Line 16 + Line 17b

(19) Total ALC Payment Inlier Tab, Line 13a or 13b

(20) Total Transfer Payment with ALC Payment at 100%

Line 18a (or 18b) + Line 19

Note 1:




TRANSFER PAYMENT:

CALCULATION OF TRANSFER PAYMENT:

Total Transfer Payment cannot exceed amount that would have been paid if the patient had been discharged (Inlier Payment)

Total Transfer Payment cannot exceed amount that would have been paid if the patient had been discharged (Inlier Payment).

30


WORKER'S COMP - NO FAULTHIGH COST OUTLIER PAYMENT





(1) Total Inpatient Gross Charges Per Patient UB-92, HCFA 1450

Revenue Code 0001

(2) Adjustment to Total Inpatient Gross Charges

a. Telephone and Telegraph Revenue Code 0964b. Television and Radio Revenue Code 0963c. Private Room Differential Non-Covered Revenue d. Other Non-Covered e. Gross Charges for all ALC Days Charge Analysisf. Total Adjustments Sum of Lines 2a thru 2e

(3) Net Inpatient Gross Charges Line 1 - Line 2f

(4) High Cost Charge Converter PUB_IP_WCNF_Acute_Col 5

(5) Net Inpatient Gross Charges Converted to Costs Line 3 x Line 4

(6) Threshold Calculation:

a. APR-DRG Cost Outlier Threshold Outlier Threshold Table (DOH*) b. Institution-Specific Adjustment Factor (ISAF/WEF)

PUB_IP_WCNF_Acute_Col 4

c. Adjusted Cost Outlier Threshold Line 6a x Line 6b

(7) High Cost Payment Test:

a. Do costs exceed the threshold? Is Line 5 > 6c?b. Does the case involve a Transfer? Determination per Your Hospital Data


(8) High Cost Outlier Payment before Inlier and ALC (100% of costs above adjusted threshold) Line 5 - Line 6c

(9) Total Inlier at 100% Inlier tab, Line 6(10) Total Payment to Provider at 100% =Line 8 + Line 9



(12a) Payment to Hospital - Surcharge paid Directly to pool Line 10 x Surcharge %


(13) Total ALC Payment Inlier Tab, Line 13a or 13b




HIGH COST OUTLIER PAYMENT:

HIGH COST OUTLIER PAYMENT IS IN ADDITION TO INLIER PAYMENT CALCULATED ON THE INLIER WORKSHEET TAB.

HIGH COST OUTLIER PAYMENT:

CONTINUE WITH CALCULATION IF LINE 7a= "Yes" AND THE CASE IS NOT A TRANSFER.

31


WORKER'S COMP - NO FAULTEXEMPT UNIT/HOSPITAL - PAYMENTS





(1) Acute Per Diem Rate PUB_IP_WCNF_EU_Applicable EU Rate (col 1 or 3 or 5 or 7 or 9)

(2) Exempt Unit/Hospital Stay Days

a. Total Number of Days in Stay (inc. ALC) Medical Record

b. Alternate Level of Care (ALC) Days Medical Record

c. Total Acute Care Days excluding ALC Line 2a - Line 2b

(3) Total Exempt Unit/Hospital Acute Care Payment Before Public Goods Pool Surcharge Line 1 x Line 2c

(4a) Public Goods Surcharge - Pay directly to Pool (see footnote for table of values) Line 3 x Surcharge %

(4b) Public Goods Surcharge - Pay to Hospital (see footnote for table of values) Line 3 x Surcharge %

(5a) Payment to Hospital - Surcharge paid Directly to pool

Line 3


EXEMPT UNIT/HOSPITAL ALTERNATE LEVEL OF CARE PAYMENT: Data Source

(6) Alternate Level of Care Per Diem PUB_IP_WCNF_EU_Applicable EU ALC Rate Code (col 2 or 4 or 6 or 8 or 10)

(7) Number of ALC Days Line 2b

(8) Total ALC Payment Prior to Public Goods Pool Surcharge

Line 6 x Line 7







EXEMPT UNIT/HOSPITAL ACUTE CARE PAYMENT:

32

APR-DRG SEVERITY APR-DRG DESCRIPTION APR -DRG SIW STATEWIDE

ALOS

001 1 Liver Transplant 11.2591 23001 2 Liver Transplant 11.3077 23001 3 Liver Transplant 13.3206 23001 4 Liver Transplant 22.8851 23002 1 Heart &/or Lung Transplant 13.6129 34002 2 Heart &/or Lung Transplant 14.8081 34002 3 Heart &/or Lung Transplant 17.8082 34002 4 Heart &/or Lung Transplant 33.2376 34003 1 Bone Marrow Transplant 7.4096 29003 2 Bone Marrow Transplant 10.2669 29003 3 Bone Marrow Transplant 17.5688 29003 4 Bone Marrow Transplant 30.3654 29004 1 Tracheostomy W Long Term Mechanical Ventilation W Extensive Procedure 9.7627 54004 2 Tracheostomy W Long Term Mechanical Ventilation W Extensive Procedure 9.7753 54004 3 Tracheostomy W Long Term Mechanical Ventilation W Extensive Procedure 13.6425 54004 4 Tracheostomy W Long Term Mechanical Ventilation W Extensive Procedure 22.2998 54005 1 Tracheostomy W Long Term Mechanical Ventilation W/O Extensive Procedure 7.8054 45005 2 Tracheostomy W Long Term Mechanical Ventilation W/O Extensive Procedure 7.7855 45005 3 Tracheostomy W Long Term Mechanical Ventilation W/O Extensive Procedure 10.6360 45005 4 Tracheostomy W Long Term Mechanical Ventilation W/O Extensive Procedure 15.7494 45006 1 Pancreas Transplant 9.3040 11006 2 Pancreas Transplant 9.3040 11006 3 Pancreas Transplant 9.3040 11006 4 Pancreas Transplant 9.3040 11020 1 Craniotomy for Trauma 1.9699 9020 2 Craniotomy for Trauma 2.7488 9020 3 Craniotomy for Trauma 4.0297 9020 4 Craniotomy for Trauma 7.6304 9021 1 Craniotomy Except for Trauma 2.1273 9021 2 Craniotomy Except for Trauma 2.9476 9021 3 Craniotomy Except for Trauma 5.8447 9021 4 Craniotomy Except for Trauma 10.2294 9022 1 Ventricular Shunt Procedures 1.2436 6022 2 Ventricular Shunt Procedures 1.6597 6022 3 Ventricular Shunt Procedures 4.1349 6022 4 Ventricular Shunt Procedures 9.2331 6023 1 Spinal Procedures 1.5389 7023 2 Spinal Procedures 2.3630 7023 3 Spinal Procedures 3.6165 7023 4 Spinal Procedures 9.3062 7024 1 Extracranial Vascular Procedures 1.2745 3024 2 Extracranial Vascular Procedures 1.7074 3024 3 Extracranial Vascular Procedures 3.6016 3024 4 Extracranial Vascular Procedures 8.7873 3026 1 Other Nervous System & Related Procedures 1.1955 5026 2 Other Nervous System & Related Procedures 1.9778 5026 3 Other Nervous System & Related Procedures 3.2369 5026 4 Other Nervous System & Related Procedures 10.3550 5040 1 Spinal Disorders & Injuries 0.9250 6040 2 Spinal Disorders & Injuries 1.2622 6040 3 Spinal Disorders & Injuries 2.3718 6040 4 Spinal Disorders & Injuries 2.8992 6041 1 Nervous System Malignancy 0.8253 7041 2 Nervous System Malignancy 0.9949 7

APR-DRG Weights and Average Length of Stays

33


ALOS

041 3 Nervous System Malignancy 1.8600 7041 4 Nervous System Malignancy 3.7112 7042 1 Degenerative Nervous System Disorders Exc Mult Sclerosis 0.6569 7042 2 Degenerative Nervous System Disorders Exc Mult Sclerosis 1.0588 7042 3 Degenerative Nervous System Disorders Exc Mult Sclerosis 1.8232 7042 4 Degenerative Nervous System Disorders Exc Mult Sclerosis 4.6740 7043 1 Multiple Sclerosis & Other Demyelinating Diseases 0.7696 5043 2 Multiple Sclerosis & Other Demyelinating Diseases 0.9740 5043 3 Multiple Sclerosis & Other Demyelinating Diseases 2.0660 5043 4 Multiple Sclerosis & Other Demyelinating Diseases 5.0436 5044 1 Intracranial Hemorrhage 1.1022 7044 2 Intracranial Hemorrhage 1.5437 7044 3 Intracranial Hemorrhage 2.1177 7044 4 Intracranial Hemorrhage 3.2759 7045 1 CVA & Precerebral Occulusion w/ Infarct 0.8917 6045 2 CVA & Precerebral Occulusion w/ Infarct 1.1197 6045 3 CVA & Precerebral Occulusion w/ Infarct 1.8447 6045 4 CVA & Precerebral Occulusion w/ Infarct 3.9081 6046 1 Nonspecific CVA & Precerebral Occlusion w/o Infarct 0.7288 4046 2 Nonspecific CVA & Precerebral Occlusion w/o Infarct 0.8867 4046 3 Nonspecific CVA & Precerebral Occlusion w/o Infarct 1.4181 4046 4 Nonspecific CVA & Precerebral Occlusion w/o Infarct 1.4282 4047 1 Transient Ischemia 0.5461 3047 2 Transient Ischemia 0.6538 3047 3 Transient Ischemia 0.9431 3047 4 Transient Ischemia 0.9707 3048 1 Peripheral, Cranial & Autonomic Nerve Disorders 0.5963 5048 2 Peripheral, Cranial & Autonomic Nerve Disorders 0.8294 5048 3 Peripheral, Cranial & Autonomic Nerve Disorders 1.2939 5048 4 Peripheral, Cranial & Autonomic Nerve Disorders 3.4657 5049 1 Bacterial & Tuberculous Infections of Nervous System 1.4540 10049 2 Bacterial & Tuberculous Infections of Nervous System 2.2000 10049 3 Bacterial & Tuberculous Infections of Nervous System 3.1251 10049 4 Bacterial & Tuberculous Infections of Nervous System 6.0621 10050 1 Non-bacterial Infections of Nervous System Exc Viral Meningitis 0.9077 8050 2 Non-bacterial Infections of Nervous System Exc Viral Meningitis 1.3695 8050 3 Non-bacterial Infections of Nervous System Exc Viral Meningitis 2.4616 8050 4 Non-bacterial Infections of Nervous System Exc Viral Meningitis 5.6151 8051 1 Viral Meningitis 0.6341 4051 2 Viral Meningitis 0.9197 4051 3 Viral Meningitis 1.5196 4051 4 Viral Meningitis 1.7498 4052 1 Nontraumatic Stupor & Coma 0.4944 5052 2 Nontraumatic Stupor & Coma 0.6993 5052 3 Nontraumatic Stupor & Coma 1.3008 5052 4 Nontraumatic Stupor & Coma 3.3792 5053 1 Seizure 0.4755 3053 2 Seizure 0.6051 3053 3 Seizure 1.0622 3053 4 Seizure 2.9651 3054 1 Migraine & Other Headaches 0.4877 3054 2 Migraine & Other Headaches 0.5917 3054 3 Migraine & Other Headaches 0.7905 3054 4 Migraine & Other Headaches 0.8360 3055 1 Head Trauma w/ Coma > 1 Hr or Hemorrhage 0.6348 4055 2 Head Trauma w/ Coma > 1 Hr or Hemorrhage 1.0109 4055 3 Head Trauma w/ Coma > 1 Hr or Hemorrhage 1.8996 4

34


ALOS

055 4 Head Trauma w/ Coma > 1 Hr or Hemorrhage 4.5148 4056 1 Brain Contusion/Laceration & Compliated Skull FX, COMA < 1 HR OR No Coma 0.5482 4056 2 Brain Contusion/Laceration & Compliated Skull FX, COMA < 1 HR OR No Coma 0.9305 4056 3 Brain Contusion/Laceration & Compliated Skull FX, COMA < 1 HR OR No Coma 1.9386 4056 4 Brain Contusion/Laceration & Compliated Skull FX, COMA < 1 HR OR No Coma 2.5204 4057 1 Concussion, Closed Skull FX Nos, Uncomplicated Intracranial Injury, Coma <1 Hr or No Coma 0.3761 2057 2 Concussion, Closed Skull FX Nos, Uncomplicated Intracranial Injury, Coma <1 Hr or No Coma 0.5792 2057 3 Concussion, Closed Skull FX Nos, Uncomplicated Intracranial Injury, Coma <1 Hr or No Coma 1.1529 2057 4 Concussion, Closed Skull FX Nos, Uncomplicated Intracranial Injury, Coma <1 Hr or No Coma 1.4968 2058 1 Other Disorders of Nervous System 0.5844 4058 2 Other Disorders of Nervous System 0.8612 4058 3 Other Disorders of Nervous System 1.6115 4058 4 Other Disorders of Nervous System 3.8891 4070 1 Orbital Procedures 0.7503 3070 2 Orbital Procedures 1.2400 3070 3 Orbital Procedures 2.9259 3070 4 Orbital Procedures 2.9856 3073 1 Eye Procedures Except Orbit 0.7015 2073 2 Eye Procedures Except Orbit 0.8931 2073 3 Eye Procedures Except Orbit 1.3459 2073 4 Eye Procedures Except Orbit 1.7039 2080 1 Acute Major Eye Infections 0.5442 4080 2 Acute Major Eye Infections 0.7366 4080 3 Acute Major Eye Infections 1.3108 4080 4 Acute Major Eye Infections 1.3896 4082 1 Eye Disorders Except Major Infections 0.5132 3082 2 Eye Disorders Except Major Infections 0.6294 3082 3 Eye Disorders Except Major Infections 1.1158 3082 4 Eye Disorders Except Major Infections 1.2757 3089 1 Major Cranial/Facial Bone Procedures 1.4268 4089 2 Major Cranial/Facial Bone Procedures 2.1653 4089 3 Major Cranial/Facial Bone Procedures 3.6184 4089 4 Major Cranial/Facial Bone Procedures 12.2398 4090 1 Major Larynx & Trachea Procedures 0.7908 11090 2 Major Larynx & Trachea Procedures 2.6285 11090 3 Major Larynx & Trachea Procedures 4.8318 11090 4 Major Larynx & Trachea Procedures 5.8747 11091 1 Other Major Head & Neck Procedures 1.3758 3091 2 Other Major Head & Neck Procedures 3.2885 3091 3 Other Major Head & Neck Procedures 4.0503 3091 4 Other Major Head & Neck Procedures 4.0671 3092 1 Facial Bone Procedures Except Major Cranial/Facial Bone Procedures 1.0186 3092 2 Facial Bone Procedures Except Major Cranial/Facial Bone Procedures 1.3035 3092 3 Facial Bone Procedures Except Major Cranial/Facial Bone Procedures 2.4137 3092 4 Facial Bone Procedures Except Major Cranial/Facial Bone Procedures 2.7980 3093 1 Sinus & Mastoid Procedures 0.8108 3093 2 Sinus & Mastoid Procedures 1.2762 3093 3 Sinus & Mastoid Procedures 2.5904 3093 4 Sinus & Mastoid Procedures 2.7012 3095 1 Cleft Lip & Palate Repair 0.6932 1095 2 Cleft Lip & Palate Repair 0.8471 1095 3 Cleft Lip & Palate Repair 1.3900 1095 4 Cleft Lip & Palate Repair 1.5315 1097 1 Tonsill & Adenoid Procedures 0.4911 2097 2 Tonsill & Adenoid Procedures 0.7436 2097 3 Tonsill & Adenoid Procedures 1.4283 2097 4 Tonsill & Adenoid Procedures 1.6145 2

35


ALOS

098 1 Other Ear, Nose, Mouth & Throat Procedures 0.7156 3098 2 Other Ear, Nose, Mouth & Throat Procedures 0.9980 3098 3 Other Ear, Nose, Mouth & Throat Procedures 2.0753 3098 4 Other Ear, Nose, Mouth & Throat Procedures 4.5670 3110 1 Ear, Nose, Mouth Throat, Cranial/Facial Malignancies 0.5752 7110 2 Ear, Nose, Mouth Throat, Cranial/Facial Malignancies 0.8827 7110 3 Ear, Nose, Mouth Throat, Cranial/Facial Malignancies 1.7441 7110 4 Ear, Nose, Mouth Throat, Cranial/Facial Malignancies 4.3057 7111 1 Vertigo & Other Labyrinth Disorders 0.4466 2111 2 Vertigo & Other Labyrinth Disorders 0.5590 2111 3 Vertigo & Other Labyrinth Disorders 0.8007 2111 4 Vertigo & Other Labyrinth Disorders 0.8243 2113 1 Infections Of The Upper Respiratory Tract 0.3837 2113 2 Infections Of The Upper Respiratory Tract 0.5005 2113 3 Infections Of The Upper Respiratory Tract 0.7793 2113 4 Infections Of The Upper Respiratory Tract 2.1444 2114 1 Dental & Oral Diseases & Injuries 0.4958 3114 2 Dental & Oral Diseases & Injuries 0.6511 3114 3 Dental & Oral Diseases & Injuries 1.2191 3114 4 Dental & Oral Diseases & Injuries 1.2679 3115 1 Other Ear, Nose, Mouth,Throat & Cranial/Facial Diagnoses 0.4632 3115 2 Other Ear, Nose, Mouth,Throat & Cranial/Facial Diagnoses 0.6329 3115 3 Other Ear, Nose, Mouth,Throat & Cranial/Facial Diagnoses 1.2571 3115 4 Other Ear, Nose, Mouth,Throat & Cranial/Facial Diagnoses 2.8560 3120 1 Major Respiratory & Chest Procedures 1.9353 9120 2 Major Respiratory & Chest Procedures 2.5058 9120 3 Major Respiratory & Chest Procedures 4.0015 9120 4 Major Respiratory & Chest Procedures 7.8523 9121 1 Other Respiratory & Chest Procedures 1.3440 7121 2 Other Respiratory & Chest Procedures 1.8580 7121 3 Other Respiratory & Chest Procedures 3.5111 7121 4 Other Respiratory & Chest Procedures 7.2613 7130 1 Respiratory System Diagnosis w/ Ventilator Support 96+ Hours 3.1239 16130 2 Respiratory System Diagnosis w/ Ventilator Support 96+ Hours 3.3872 16130 3 Respiratory System Diagnosis w/ Ventilator Support 96+ Hours 4.3025 16130 4 Respiratory System Diagnosis w/ Ventilator Support 96+ Hours 6.4532 16131 1 Cystic Fibrosis - Pulmonary Disease 1.4054 9131 2 Cystic Fibrosis - Pulmonary Disease 1.5209 9131 3 Cystic Fibrosis - Pulmonary Disease 1.9354 9131 4 Cystic Fibrosis - Pulmonary Disease 3.0674 9132 1 BPD & Oth Chronic Respiratory Dis Arising In Perinatal Period 0.5706 7132 2 BPD & Oth Chronic Respiratory Dis Arising In Perinatal Period 0.8798 7132 3 BPD & Oth Chronic Respiratory Dis Arising In Perinatal Period 1.5839 7132 4 BPD & Oth Chronic Respiratory Dis Arising In Perinatal Period 3.3598 7133 1 Pulmonary Edema & Respiratory Failure 0.5500 7133 2 Pulmonary Edema & Respiratory Failure 1.0586 7133 3 Pulmonary Edema & Respiratory Failure 1.5460 7133 4 Pulmonary Edema & Respiratory Failure 2.2667 7134 1 Pulmonary Embolism 0.9446 6134 2 Pulmonary Embolism 1.1935 6134 3 Pulmonary Embolism 1.8021 6134 4 Pulmonary Embolism 2.9754 6135 1 Major Chest & Respiratory Trauma 0.5861 4135 2 Major Chest & Respiratory Trauma 0.8579 4135 3 Major Chest & Respiratory Trauma 1.4048 4135 4 Major Chest & Respiratory Trauma 2.3700 4136 1 Respiratory Malignancy 0.7011 8

36


ALOS

136 2 Respiratory Malignancy 1.0296 8136 3 Respiratory Malignancy 1.9292 8136 4 Respiratory Malignancy 3.1154 8137 1 Major Respiratory Infections & Inflammations 1.0748 9137 2 Major Respiratory Infections & Inflammations 1.2256 9137 3 Major Respiratory Infections & Inflammations 1.8515 9137 4 Major Respiratory Infections & Inflammations 3.0650 9138 1 Bronchiolitis & RSV Pneumonia 0.4810 3138 2 Bronchiolitis & RSV Pneumonia 0.6690 3138 3 Bronchiolitis & RSV Pneumonia 1.2044 3138 4 Bronchiolitis & RSV Pneumonia 2.1470 3139 1 Other Pneumonia 0.5328 4139 2 Other Pneumonia 0.7683 4139 3 Other Pneumonia 1.2634 4139 4 Other Pneumonia 2.4082 4140 1 Chronic Obstructive Pulmonary Disease 0.6384 5140 2 Chronic Obstructive Pulmonary Disease 0.8242 5140 3 Chronic Obstructive Pulmonary Disease 1.2019 5140 4 Chronic Obstructive Pulmonary Disease 2.3575 5141 1 Asthma 0.4602 3141 2 Asthma 0.6103 3141 3 Asthma 0.9163 3141 4 Asthma 1.5447 3142 1 Interstitial Lung Disease 0.8018 6142 2 Interstitial Lung Disease 1.0124 6142 3 Interstitial Lung Disease 1.4267 6142 4 Interstitial Lung Disease 2.5265 6143 1 Other Respiratory Diagnosis Except Signs, Symptoms & Minor Diagnoses 0.5696 4143 2 Other Respiratory Diagnosis Except Signs, Symptoms & Minor Diagnoses 0.8483 4143 3 Other Respiratory Diagnosis Except Signs, Symptoms & Minor Diagnoses 1.3238 4143 4 Other Respiratory Diagnosis Except Signs, Symptoms & Minor Diagnoses 2.1420 4144 1 Respiratory System Signs, Symptoms & Other Diagnoses 0.4697 3144 2 Respiratory System Signs, Symptoms & Other Diagnoses 0.6025 3144 3 Respiratory System Signs, Symptoms & Other Diagnoses 0.8738 3144 4 Respiratory System Signs, Symptoms & Other Diagnoses 1.8810 3160 1 Major Cardiothoracic Repair of Heart Anomaly 2.8080 9160 2 Major Cardiothoracic Repair of Heart Anomaly 3.5119 9160 3 Major Cardiothoracic Repair of Heart Anomaly 5.5637 9160 4 Major Cardiothoracic Repair of Heart Anomaly 9.4460 9161 1 Cardiac Defibrillator & Heart Assist Anomaly 4.8871 6161 2 Cardiac Defibrillator & Heart Assist Anomaly 5.5255 6161 3 Cardiac Defibrillator & Heart Assist Anomaly 6.3380 6161 4 Cardiac Defibrillator & Heart Assist Anomaly 18.3834 6162 1 Cardiac Valve Procedures w/ Cardiac Catheterization 4.3297 12162 2 Cardiac Valve Procedures w/ Cardiac Catheterization 5.2818 12162 3 Cardiac Valve Procedures w/ Cardiac Catheterization 6.5998 12162 4 Cardiac Valve Procedures w/ Cardiac Catheterization 11.1127 12163 1 Cardiac Valve Procedures w/o Cardiac Catheterization 3.5266 9163 2 Cardiac Valve Procedures w/o Cardiac Catheterization 4.3476 9163 3 Cardiac Valve Procedures w/o Cardiac Catheterization 5.5799 9163 4 Cardiac Valve Procedures w/o Cardiac Catheterization 10.8792 9165 1 Coronary Bypass w/ Cardiac Cath Or Percutaneous Cardiac Procedure 3.6768 9165 2 Coronary Bypass w/ Cardiac Cath Or Percutaneous Cardiac Procedure 4.2753 9165 3 Coronary Bypass w/ Cardiac Cath Or Percutaneous Cardiac Procedure 5.4572 9165 4 Coronary Bypass w/ Cardiac Cath Or Percutaneous Cardiac Procedure 8.9906 9166 1 Coronary Bypass w/o Cardiac Cath Or Percutaneous Cardiac Procedure 2.8908 7166 2 Coronary Bypass w/o Cardiac Cath Or Percutaneous Cardiac Procedure 3.3676 7

37


ALOS

166 3 Coronary Bypass w/o Cardiac Cath Or Percutaneous Cardiac Procedure 4.3891 7166 4 Coronary Bypass w/o Cardiac Cath Or Percutaneous Cardiac Procedure 7.6642 7167 1 Other Cardiothoracic Procedures 2.5136 7167 2 Other Cardiothoracic Procedures 3.3812 7167 3 Other Cardiothoracic Procedures 4.4135 7167 4 Other Cardiothoracic Procedures 7.8116 7169 1 Major Thoracic & Abdominal Vascular Procedures 1.7804 9169 2 Major Thoracic & Abdominal Vascular Procedures 2.6289 9169 3 Major Thoracic & Abdominal Vascular Procedures 4.3360 9169 4 Major Thoracic & Abdominal Vascular Procedures 9.0544 9170 1 Permanent Cardiac Pacemaker Implant w/ AMI, Heart Failure or Shock 3.3074 10170 2 Permanent Cardiac Pacemaker Implant w/ AMI, Heart Failure or Shock 3.3716 10170 3 Permanent Cardiac Pacemaker Implant w/ AMI, Heart Failure or Shock 4.4399 10170 4 Permanent Cardiac Pacemaker Implant w/ AMI, Heart Failure or Shock 4.8467 10171 1 Perm Cardiac Pacemaker Implant w/o AMI, Heart Failure or Shock 2.0836 4171 2 Perm Cardiac Pacemaker Implant w/o AMI, Heart Failure or Shock 2.5077 4171 3 Perm Cardiac Pacemaker Implant w/o AMI, Heart Failure or Shock 3.4714 4171 4 Perm Cardiac Pacemaker Implant w/o AMI, Heart Failure or Shock 6.5200 4173 1 Other Vascular Procedures 1.5767 6173 2 Other Vascular Procedures 2.1735 6173 3 Other Vascular Procedures 3.5138 6173 4 Other Vascular Procedures 7.7352 6174 1 Percutaneous Cardiovascular Procedures w/ AMI 2.3132 3174 2 Percutaneous Cardiovascular Procedures w/ AMI 2.5355 3174 3 Percutaneous Cardiovascular Procedures w/ AMI 3.2391 3174 4 Percutaneous Cardiovascular Procedures w/ AMI 4.4635 3175 1 Percutaneous Cardiovascular Procedures w/o AMI 1.7179 2175 2 Percutaneous Cardiovascular Procedures w/o AMI 1.8561 2175 3 Percutaneous Cardiovascular Procedures w/o AMI 2.4887 2175 4 Percutaneous Cardiovascular Procedures w/o AMI 4.5837 2176 1 Cardiac Pacemaker & Defibrillator Device Replacement 1.4317 2176 2 Cardiac Pacemaker & Defibrillator Device Replacement 3.2942 2176 3 Cardiac Pacemaker & Defibrillator Device Replacement 3.5473 2176 4 Cardiac Pacemaker & Defibrillator Device Replacement 3.6174 2177 1 Cardiac Pacemaker & Defibrillator Revision Except Device Replacement 1.2442 4177 2 Cardiac Pacemaker & Defibrillator Revision Except Device Replacement 1.7622 4177 3 Cardiac Pacemaker & Defibrillator Revision Except Device Replacement 2.9362 4177 4 Cardiac Pacemaker & Defibrillator Revision Except Device Replacement 5.6793 4180 1 Other Circulatory System Procedures 1.1419 10180 2 Other Circulatory System Procedures 1.8845 10180 3 Other Circulatory System Procedures 3.1003 10180 4 Other Circulatory System Procedures 6.5236 10190 1 Acute Myocardial Infarction 0.9013 5190 2 Acute Myocardial Infarction 1.1381 5190 3 Acute Myocardial Infarction 1.6816 5190 4 Acute Myocardial Infarction 3.1320 5191 1 Cardiac Catheterization w/ Circ Disord Exc Ischemic Heart Disease 0.9435 5191 2 Cardiac Catheterization w/ Circ Disord Exc Ischemic Heart Disease 1.1899 5191 3 Cardiac Catheterization w/ Circ Disord Exc Ischemic Heart Disease 1.6188 5191 4 Cardiac Catheterization w/ Circ Disord Exc Ischemic Heart Disease 4.1311 5192 1 Cardiac Catheterization for Ischemic Heart Disease 0.7542 2192 2 Cardiac Catheterization for Ischemic Heart Disease 0.9095 2192 3 Cardiac Catheterization for Ischemic Heart Disease 1.2993 2192 4 Cardiac Catheterization for Ischemic Heart Disease 2.4918 2193 1 Acute & Subacute Endocarditis 1.0944 13193 2 Acute & Subacute Endocarditis 1.5304 13193 3 Acute & Subacute Endocarditis 2.8338 13

38


ALOS

193 4 Acute & Subacute Endocarditis 4.9338 13194 1 Heart Failure 0.6187 5194 2 Heart Failure 0.8679 5194 3 Heart Failure 1.4312 5194 4 Heart Failure 3.3765 5196 1 Cardiac Arrest 0.3101 4196 2 Cardiac Arrest 0.5013 4196 3 Cardiac Arrest 1.0035 4196 4 Cardiac Arrest 2.6008 4197 1 Peripheral & Other Vascular Disorders 0.6665 5197 2 Peripheral & Other Vascular Disorders 0.9044 5197 3 Peripheral & Other Vascular Disorders 1.4218 5197 4 Peripheral & Other Vascular Disorders 2.8980 5198 1 Angina Pectoris & Coronary Atherosclerosis 0.4318 2198 2 Angina Pectoris & Coronary Atherosclerosis 0.5554 2198 3 Angina Pectoris & Coronary Atherosclerosis 0.7878 2198 4 Angina Pectoris & Coronary Atherosclerosis 1.5782 2199 1 Hypertension 0.4621 3199 2 Hypertension 0.6099 3199 3 Hypertension 0.9823 3199 4 Hypertension 2.8971 3200 1 Cardiac Congenital & Valvular Disorders 0.4988 5200 2 Cardiac Congenital & Valvular Disorders 0.7742 5200 3 Cardiac Congenital & Valvular Disorders 1.2301 5200 4 Cardiac Congenital & Valvular Disorders 5.0753 5201 1 Cardiac Arrhythmia & Conduction Disorders 0.4749 3201 2 Cardiac Arrhythmia & Conduction Disorders 0.6758 3201 3 Cardiac Arrhythmia & Conduction Disorders 1.1358 3201 4 Cardiac Arrhythmia & Conduction Disorders 2.8229 3203 1 Chest Pain 0.3854 2203 2 Chest Pain 0.4754 2203 3 Chest Pain 0.6751 2203 4 Chest Pain 1.6182 2204 1 Syncope & Collapse 0.4598 3204 2 Syncope & Collapse 0.6003 3204 3 Syncope & Collapse 0.9056 3204 4 Syncope & Collapse 1.8868 3205 1 Cardiomyopathy 0.5433 4205 2 Cardiomyopathy 0.7042 4205 3 Cardiomyopathy 1.1405 4205 4 Cardiomyopathy 1.2908 4206 1 Malfunction, Reaction & Comp of Cardiac or Vasc Device or Proc 0.6501 7206 2 Malfunction, Reaction & Comp of Cardiac or Vasc Device or Proc 0.8746 7206 3 Malfunction, Reaction & Comp of Cardiac or Vasc Device or Proc 1.5777 7206 4 Malfunction, Reaction & Comp of Cardiac or Vasc Device or Proc 3.2453 7207 1 Other Circulatory System Diagnoses 0.5254 3207 2 Other Circulatory System Diagnoses 0.7849 3207 3 Other Circulatory System Diagnoses 1.3256 3207 4 Other Circulatory System Diagnoses 2.7610 3220 1 Major Stomach, Esophageal & Duodenal Procedures 1.3363 10220 2 Major Stomach, Esophageal & Duodenal Procedures 2.2346 10220 3 Major Stomach, Esophageal & Duodenal Procedures 4.0005 10220 4 Major Stomach, Esophageal & Duodenal Procedures 9.1055 10221 1 Major Small & Large Bowel Procedures 1.5190 9221 2 Major Small & Large Bowel Procedures 1.9908 9221 3 Major Small & Large Bowel Procedures 3.4044 9221 4 Major Small & Large Bowel Procedures 7.2287 9

39


ALOS

222 1 Minor Stomach, Esophageal & Duodenal Procedures 0.8701 4222 2 Minor Stomach, Esophageal & Duodenal Procedures 1.2390 4222 3 Minor Stomach, Esophageal & Duodenal Procedures 2.5232 4222 4 Minor Stomach, Esophageal & Duodenal Procedures 7.6549 4223 1 Minor Small & Large Bowel Procedures 1.2110 7223 2 Minor Small & Large Bowel Procedures 1.6705 7223 3 Minor Small & Large Bowel Procedures 2.5639 7223 4 Minor Small & Large Bowel Procedures 7.9293 7224 1 Peritoneal Adhesiolysis 1.2985 8224 2 Peritoneal Adhesiolysis 1.7783 8224 3 Peritoneal Adhesiolysis 2.9554 8224 4 Peritoneal Adhesiolysis 6.0676 8225 1 Appendectomy 0.7478 3225 2 Appendectomy 1.1213 3225 3 Appendectomy 2.1513 3225 4 Appendectomy 4.9038 3226 1 Anal Procedures 0.6345 3226 2 Anal Procedures 0.8794 3226 3 Anal Procedures 1.8153 3226 4 Anal Procedures 4.2341 3227 1 Hernia Procedures Except Inguinal, Femoral & Umbilical 0.9602 4227 2 Hernia Procedures Except Inguinal, Femoral & Umbilical 1.2907 4227 3 Hernia Procedures Except Inguinal, Femoral & Umbilical 2.1644 4227 4 Hernia Procedures Except Inguinal, Femoral & Umbilical 5.2790 4228 1 Inguinal, Femoral & Umbilical Hernia Procedures 0.6716 2228 2 Inguinal, Femoral & Umbilical Hernia Procedures 0.9587 2228 3 Inguinal, Femoral & Umbilical Hernia Procedures 1.6463 2228 4 Inguinal, Femoral & Umbilical Hernia Procedures 4.9025 2229 1 Other Digestive System & Abdominal Procedures 1.1048 8229 2 Other Digestive System & Abdominal Procedures 1.7146 8229 3 Other Digestive System & Abdominal Procedures 3.1968 8229 4 Other Digestive System & Abdominal Procedures 6.5728 8240 1 Digestive Malignancy 0.6492 8240 2 Digestive Malignancy 1.0044 8240 3 Digestive Malignancy 1.9238 8240 4 Digestive Malignancy 3.8442 8241 1 Peptic Ulcer & Gastritis 0.5527 3241 2 Peptic Ulcer & Gastritis 0.8122 3241 3 Peptic Ulcer & Gastritis 1.3253 3241 4 Peptic Ulcer & Gastritis 3.4622 3242 1 Major Esophageal Disorders 0.5574 5242 2 Major Esophageal Disorders 0.8806 5242 3 Major Esophageal Disorders 1.3941 5242 4 Major Esophageal Disorders 3.3446 5243 1 Other Esophageal Disorders 0.4638 3243 2 Other Esophageal Disorders 0.6587 3243 3 Other Esophageal Disorders 1.1782 3243 4 Other Esophageal Disorders 3.0450 3244 1 Diverticulitis & Diverticulosis 0.5855 4244 2 Diverticulitis & Diverticulosis 0.7764 4244 3 Diverticulitis & Diverticulosis 1.2632 4244 4 Diverticulitis & Diverticulosis 2.8430 4245 1 Inflammatory Bowel Disease 0.6869 5245 2 Inflammatory Bowel Disease 0.8827 5245 3 Inflammatory Bowel Disease 1.5130 5245 4 Inflammatory Bowel Disease 3.0244 5246 1 Gastrointestinal Vascular Insufficiency 0.6896 5

40


ALOS

246 2 Gastrointestinal Vascular Insufficiency 0.9099 5246 3 Gastrointestinal Vascular Insufficiency 1.5743 5246 4 Gastrointestinal Vascular Insufficiency 4.0183 5247 1 Intestinal Obstruction 0.5441 4247 2 Intestinal Obstruction 0.7523 4247 3 Intestinal Obstruction 1.2350 4247 4 Intestinal Obstruction 3.0969 4248 1 Major Gastrointestinal & Peritoneal Infections 0.6066 6248 2 Major Gastrointestinal & Peritoneal Infections 0.9215 6248 3 Major Gastrointestinal & Peritoneal Infections 1.5397 6248 4 Major Gastrointestinal & Peritoneal Infections 3.4199 6249 1 Non-Bacterial Gastroenteritis, Nausea & Vomiting 0.3896 3249 2 Non-Bacterial Gastroenteritis, Nausea & Vomiting 0.5265 3249 3 Non-Bacterial Gastroenteritis, Nausea & Vomiting 0.8284 3249 4 Non-Bacterial Gastroenteritis, Nausea & Vomiting 2.1676 3251 1 Abdominal Pain 0.4242 3251 2 Abdominal Pain 0.5998 3251 3 Abdominal Pain 0.9196 3251 4 Abdominal Pain 1.6576 3252 1 Malfunction, Reaction & Complication Of G.I. Device Or Procedure 0.5937 5252 2 Malfunction, Reaction & Complication Of G.I. Device Or Procedure 0.8219 5252 3 Malfunction, Reaction & Complication Of G.I. Device Or Procedure 1.3858 5252 4 Malfunction, Reaction & Complication Of G.I. Device Or Procedure 3.0873 5253 1 Other & Unspecified Gastrointestinal Hemorrhage 0.5922 4253 2 Other & Unspecified Gastrointestinal Hemorrhage 0.8274 4253 3 Other & Unspecified Gastrointestinal Hemorrhage 1.3281 4253 4 Other & Unspecified Gastrointestinal Hemorrhage 2.9247 4254 1 Other Digestive System Diagnoses 0.4955 3254 2 Other Digestive System Diagnoses 0.7724 3254 3 Other Digestive System Diagnoses 1.2467 3254 4 Other Digestive System Diagnoses 3.0522 3260 1 Major Pancreas, Liver & Shunt Procedures 1.5598 10260 2 Major Pancreas, Liver & Shunt Procedures 2.0946 10260 3 Major Pancreas, Liver & Shunt Procedures 3.9029 10260 4 Major Pancreas, Liver & Shunt Procedures 9.6119 10261 1 Major Biliary Tract Procedures 1.4437 10261 2 Major Biliary Tract Procedures 2.1580 10261 3 Major Biliary Tract Procedures 3.6514 10261 4 Major Biliary Tract Procedures 7.4013 10262 1 Cholecystectomy Except Laparoscopic 1.3236 7262 2 Cholecystectomy Except Laparoscopic 1.7463 7262 3 Cholecystectomy Except Laparoscopic 2.7036 7262 4 Cholecystectomy Except Laparoscopic 5.8510 7263 1 Laparoscopic Cholecystectomy 0.8967 4263 2 Laparoscopic Cholecystectomy 1.2542 4263 3 Laparoscopic Cholecystectomy 1.8895 4263 4 Laparoscopic Cholecystectomy 5.2196 4264 1 Other Hepatobiliary, Pancreas & Abdominal Procedures 1.3990 11264 2 Other Hepatobiliary, Pancreas & Abdominal Procedures 1.9233 11264 3 Other Hepatobiliary, Pancreas & Abdominal Procedures 3.2929 11264 4 Other Hepatobiliary, Pancreas & Abdominal Procedures 7.2776 11279 1 Hepatic Coma & Other Major Acute Liver Disorders 0.6326 7279 2 Hepatic Coma & Other Major Acute Liver Disorders 0.8736 7279 3 Hepatic Coma & Other Major Acute Liver Disorders 1.5385 7279 4 Hepatic Coma & Other Major Acute Liver Disorders 3.9010 7280 1 Alcoholic Liver Disease 0.6482 7280 2 Alcoholic Liver Disease 0.8277 7

41


ALOS

280 3 Alcoholic Liver Disease 1.4305 7280 4 Alcoholic Liver Disease 3.7633 7281 1 Malignancy of Hepatobiliary System & Pancreas 0.6913 7281 2 Malignancy of Hepatobiliary System & Pancreas 0.9976 7281 3 Malignancy of Hepatobiliary System & Pancreas 1.6231 7281 4 Malignancy of Hepatobiliary System & Pancreas 2.9782 7282 1 Disorders of Pancreas Except Malignancy 0.6580 5282 2 Disorders of Pancreas Except Malignancy 0.8893 5282 3 Disorders of Pancreas Except Malignancy 1.5922 5282 4 Disorders of Pancreas Except Malignancy 4.4306 5283 1 Other Disorders Of The Liver 0.5145 5283 2 Other Disorders Of The Liver 0.8057 5283 3 Other Disorders Of The Liver 1.3435 5283 4 Other Disorders Of The Liver 3.6055 5284 1 Disorders of the Gallbladder & Biliary Tract 0.6047 4284 2 Disorders of the Gallbladder & Biliary Tract 0.8756 4284 3 Disorders of the Gallbladder & Biliary Tract 1.4215 4284 4 Disorders of the Gallbladder & Biliary Tract 3.2713 4301 1 Hip Joint Replacement 2.2616 4301 2 Hip Joint Replacement 2.3896 4301 3 Hip Joint Replacement 2.8791 4301 4 Hip Joint Replacement 6.3785 4302 1 Knee Joint Replacement 2.0883 4302 2 Knee Joint Replacement 2.3635 4302 3 Knee Joint Replacement 2.9869 4302 4 Knee Joint Replacement 6.1293 4303 1 Dorsal & Lumbar Fusion Proc for Curvature of Back 4.1361 7303 2 Dorsal & Lumbar Fusion Proc for Curvature of Back 4.6410 7303 3 Dorsal & Lumbar Fusion Proc for Curvature of Back 7.0605 7303 4 Dorsal & Lumbar Fusion Proc for Curvature of Back 11.1463 7304 1 Dorsal & Lumbar Fusion Proc Except for Curvature of Back 3.1337 5304 2 Dorsal & Lumbar Fusion Proc Except for Curvature of Back 3.6586 5304 3 Dorsal & Lumbar Fusion Proc Except for Curvature of Back 5.5173 5304 4 Dorsal & Lumbar Fusion Proc Except for Curvature of Back 10.3026 5305 1 Amputation of Lower Limb Except Toes 1.4259 16305 2 Amputation of Lower Limb Except Toes 2.1557 16305 3 Amputation of Lower Limb Except Toes 3.3639 16305 4 Amputation of Lower Limb Except Toes 6.6181 16308 1 Hip & Femur Procedures for Trauma Except Joint Replacement 1.2777 7308 2 Hip & Femur Procedures for Trauma Except Joint Replacement 1.7415 7308 3 Hip & Femur Procedures for Trauma Except Joint Replacement 2.6470 7308 4 Hip & Femur Procedures for Trauma Except Joint Replacement 5.0488 7309 1 Hip & Femur Procedures for Non-Trauma Except Joint Replacement 1.1836 5309 2 Hip & Femur Procedures for Non-Trauma Except Joint Replacement 1.8159 5309 3 Hip & Femur Procedures for Non-Trauma Except Joint Replacement 3.4205 5309 4 Hip & Femur Procedures for Non-Trauma Except Joint Replacement 7.9117 5310 1 Intervertebral Disc Excision & Decompression 0.7798 2310 2 Intervertebral Disc Excision & Decompression 1.1201 2310 3 Intervertebral Disc Excision & Decompression 2.2596 2310 4 Intervertebral Disc Excision & Decompression 6.1374 2312 1 Skin Graft, Except Hand, For Musculoskeletal & Connective Tissue Diagnoses 1.4464 13312 2 Skin Graft, Except Hand, For Musculoskeletal & Connective Tissue Diagnoses 2.3663 13312 3 Skin Graft, Except Hand, For Musculoskeletal & Connective Tissue Diagnoses 5.4626 13312 4 Skin Graft, Except Hand, For Musculoskeletal & Connective Tissue Diagnoses 14.2000 13313 1 Knee & Lower Leg Procedures Except Foot 1.0382 4313 2 Knee & Lower Leg Procedures Except Foot 1.6028 4313 3 Knee & Lower Leg Procedures Except Foot 2.8732 4

42


ALOS

313 4 Knee & Lower Leg Procedures Except Foot 7.1784 4314 1 Foot & Toe Procedures 0.9718 6314 2 Foot & Toe Procedures 1.3504 6314 3 Foot & Toe Procedures 2.0945 6314 4 Foot & Toe Procedures 4.1122 6315 1 Shoulder, Upper Arm & Forearm Procedures 0.7893 2315 2 Shoulder, Upper Arm & Forearm Procedures 1.2949 2315 3 Shoulder, Upper Arm & Forearm Procedures 2.6557 2315 4 Shoulder, Upper Arm & Forearm Procedures 6.1511 2316 1 Hand & Wrist Procedures 0.6903 3316 2 Hand & Wrist Procedures 1.0780 3316 3 Hand & Wrist Procedures 2.7400 3316 4 Hand & Wrist Procedures 3.6853 3317 1 Tendon, Muscle & Other Soft Tissue Procedures 0.8204 4317 2 Tendon, Muscle & Other Soft Tissue Procedures 1.4365 4317 3 Tendon, Muscle & Other Soft Tissue Procedures 2.8454 4317 4 Tendon, Muscle & Other Soft Tissue Procedures 7.3972 4320 1 Other Musculoskeletel System & Connective Tissue Procedures 0.9200 5320 2 Other Musculoskeletel System & Connective Tissue Procedures 1.6503 5320 3 Other Musculoskeletel System & Connective Tissue Procedures 2.9999 5320 4 Other Musculoskeletel System & Connective Tissue Procedures 8.2132 5321 1 Cervical Spinal Fusion & Other Back/Neck Proc Exc Disc Excis/Decomp 1.5998 3321 2 Cervical Spinal Fusion & Other Back/Neck Proc Exc Disc Excis/Decomp 2.1743 3321 3 Cervical Spinal Fusion & Other Back/Neck Proc Exc Disc Excis/Decomp 4.3617 3321 4 Cervical Spinal Fusion & Other Back/Neck Proc Exc Disc Excis/Decomp 7.3095 3340 1 Fractures of Femur 0.6261 5340 2 Fractures of Femur 0.8411 5340 3 Fractures of Femur 1.5224 5340 4 Fractures of Femur 2.8408 5341 1 Fracture of Pelvis or Dislocation of Hip 0.5765 5341 2 Fracture of Pelvis or Dislocation of Hip 0.8071 5341 3 Fracture of Pelvis or Dislocation of Hip 1.1533 5341 4 Fracture of Pelvis or Dislocation of Hip 1.2131 5342 1 Fracture or Dislocation Except Femur, Pelvis & Back 0.4419 3342 2 Fracture or Dislocation Except Femur, Pelvis & Back 0.7130 3342 3 Fracture or Dislocation Except Femur, Pelvis & Back 1.2394 3342 4 Fracture or Dislocation Except Femur, Pelvis & Back 2.6250 3343 1 Musculoskeletal Malignancy & Pathol Fractures D/T Muscskel Malig 0.7918 9343 2 Musculoskeletal Malignancy & Pathol Fractures D/T Muscskel Malig 1.1182 9343 3 Musculoskeletal Malignancy & Pathol Fractures D/T Muscskel Malig 2.1264 9343 4 Musculoskeletal Malignancy & Pathol Fractures D/T Muscskel Malig 4.4498 9344 1 Osteomyelitis, Septic Arthritis & Other Musculoskeletal Infections 0.8935 9344 2 Osteomyelitis, Septic Arthritis & Other Musculoskeletal Infections 1.3016 9344 3 Osteomyelitis, Septic Arthritis & Other Musculoskeletal Infections 2.0117 9344 4 Osteomyelitis, Septic Arthritis & Other Musculoskeletal Infections 4.1630 9346 1 Connective Tissue Disorders 0.6726 5346 2 Connective Tissue Disorders 0.9333 5346 3 Connective Tissue Disorders 1.6840 5346 4 Connective Tissue Disorders 4.8574 5347 1 Other Back & Neck Disorders, Fractures & Injuries 0.5845 4347 2 Other Back & Neck Disorders, Fractures & Injuries 0.8219 4347 3 Other Back & Neck Disorders, Fractures & Injuries 1.4238 4347 4 Other Back & Neck Disorders, Fractures & Injuries 2.9592 4349 1 Malfunction, Reaction & Comp of Orthopedic Device or Procedure 0.5576 5349 2 Malfunction, Reaction & Comp of Orthopedic Device or Procedure 0.9853 5349 3 Malfunction, Reaction & Comp of Orthopedic Device or Procedure 1.5261 5349 4 Malfunction, Reaction & Comp of Orthopedic Device or Procedure 2.7758 5

43


ALOS

351 1 Other Musculoskeletal System & Connective Tissue Diagnoses 0.4832 4351 2 Other Musculoskeletal System & Connective Tissue Diagnoses 0.6731 4351 3 Other Musculoskeletal System & Connective Tissue Diagnoses 1.1864 4351 4 Other Musculoskeletal System & Connective Tissue Diagnoses 3.4957 4361 1 Skin Graft for Skin & Subcutaneous Tissue Diagnoses 1.2437 7361 2 Skin Graft for Skin & Subcutaneous Tissue Diagnoses 2.0667 7361 3 Skin Graft for Skin & Subcutaneous Tissue Diagnoses 4.0960 7361 4 Skin Graft for Skin & Subcutaneous Tissue Diagnoses 9.4766 7362 1 Mastectomy Procedures 1.0608 2362 2 Mastectomy Procedures 1.5147 2362 3 Mastectomy Procedures 1.9888 2362 4 Mastectomy Procedures 3.5526 2363 1 Breast Procedures Except Mastectomy 0.8142 2363 2 Breast Procedures Except Mastectomy 1.3290 2363 3 Breast Procedures Except Mastectomy 2.3089 2363 4 Breast Procedures Except Mastectomy 2.3304 2364 1 Other Skin, Subcutaneous Tissue & Related Procedures 0.7999 4364 2 Other Skin, Subcutaneous Tissue & Related Procedures 1.2660 4364 3 Other Skin, Subcutaneous Tissue & Related Procedures 2.6536 4364 4 Other Skin, Subcutaneous Tissue & Related Procedures 5.9077 4380 1 Skin Ulcers 0.7539 7380 2 Skin Ulcers 0.9597 7380 3 Skin Ulcers 1.4881 7380 4 Skin Ulcers 3.2915 7381 1 Major Skin Disorders 0.5820 5381 2 Major Skin Disorders 0.8793 5381 3 Major Skin Disorders 1.4663 5381 4 Major Skin Disorders 5.2122 5382 1 Malignant Breast Disorders 0.3685 7382 2 Malignant Breast Disorders 0.7981 7382 3 Malignant Breast Disorders 1.8770 7382 4 Malignant Breast Disorders 1.9984 7383 1 Cellulitis & Other Bacterial Skin Infections 0.5292 4383 2 Cellulitis & Other Bacterial Skin Infections 0.7551 4383 3 Cellulitis & Other Bacterial Skin Infections 1.2695 4383 4 Cellulitis & Other Bacterial Skin Infections 3.2191 4384 1 Contusion, Open Wound & Other Trauma To Skin & Subcutaneous Tissue 0.4192 2384 2 Contusion, Open Wound & Other Trauma To Skin & Subcutaneous Tissue 0.6013 2384 3 Contusion, Open Wound & Other Trauma To Skin & Subcutaneous Tissue 1.0810 2384 4 Contusion, Open Wound & Other Trauma To Skin & Subcutaneous Tissue 3.0177 2385 1 Other Skin, Subcutaneous Tissue & Breast Disorders 0.4631 3385 2 Other Skin, Subcutaneous Tissue & Breast Disorders 0.6498 3385 3 Other Skin, Subcutaneous Tissue & Breast Disorders 1.1411 3385 4 Other Skin, Subcutaneous Tissue & Breast Disorders 2.4690 3401 1 Pituitary & Adrenal Procedures 1.3168 5401 2 Pituitary & Adrenal Procedures 1.9462 5401 3 Pituitary & Adrenal Procedures 3.9489 5401 4 Pituitary & Adrenal Procedures 8.8971 5403 1 Procedures for Obesity 1.2850 2403 2 Procedures for Obesity 1.4273 2403 3 Procedures for Obesity 2.1585 2403 4 Procedures for Obesity 8.2043 2404 1 Thyroid, Parathyroid & Thyroglossal Procedures 0.6622 1404 2 Thyroid, Parathyroid & Thyroglossal Procedures 0.8911 1404 3 Thyroid, Parathyroid & Thyroglossal Procedures 2.5094 1404 4 Thyroid, Parathyroid & Thyroglossal Procedures 3.1023 1405 1 Other Procedures for Endocrine, Nutrititional & Metabolic Disorders 1.0792 12

44


ALOS

405 2 Other Procedures for Endocrine, Nutrititional & Metabolic Disorders 1.8552 12405 3 Other Procedures for Endocrine, Nutrititional & Metabolic Disorders 3.3794 12405 4 Other Procedures for Endocrine, Nutrititional & Metabolic Disorders 8.3170 12420 1 Diabetes 0.4709 3420 2 Diabetes 0.6713 3420 3 Diabetes 1.0249 3420 4 Diabetes 2.7260 3421 1 Malnutrition, Failure To Thrive & Other Nutritional Disorders 0.5829 6421 2 Malnutrition, Failure To Thrive & Other Nutritional Disorders 0.8305 6421 3 Malnutrition, Failure To Thrive & Other Nutritional Disorders 1.4184 6421 4 Malnutrition, Failure To Thrive & Other Nutritional Disorders 3.8215 6422 1 Hypovolemia & Related Electrolyte Disorders 0.3664 4422 2 Hypovolemia & Related Electrolyte Disorders 0.6062 4422 3 Hypovolemia & Related Electrolyte Disorders 1.0519 4422 4 Hypovolemia & Related Electrolyte Disorders 3.1695 4423 1 Inborn Errors of Metabolism 0.5362 5423 2 Inborn Errors of Metabolism 0.8323 5423 3 Inborn Errors of Metabolism 1.5588 5423 4 Inborn Errors of Metabolism 8.5460 5424 1 Other Endocrine Disorders 0.5227 4424 2 Other Endocrine Disorders 0.8141 4424 3 Other Endocrine Disorders 1.3674 4424 4 Other Endocrine Disorders 3.1643 4425 1 Electrolyte Disorders Except Hypovolemia Related 0.4551 4425 2 Electrolyte Disorders Except Hypovolemia Related 0.6409 4425 3 Electrolyte Disorders Except Hypovolemia Related 1.0090 4425 4 Electrolyte Disorders Except Hypovolemia Related 2.9088 4440 1 Kidney Transplant 6.7466 7440 2 Kidney Transplant 7.1320 7440 3 Kidney Transplant 8.3965 7440 4 Kidney Transplant 11.8643 7441 1 Major Bladder Procedures 1.3710 10441 2 Major Bladder Procedures 2.4353 10441 3 Major Bladder Procedures 3.4984 10441 4 Major Bladder Procedures 8.3247 10442 1 Kidney & Urinary Tract Procedures for Malignancy 1.3285 5442 2 Kidney & Urinary Tract Procedures for Malignancy 1.6197 5442 3 Kidney & Urinary Tract Procedures for Malignancy 2.9889 5442 4 Kidney & Urinary Tract Procedures for Malignancy 6.7989 5443 1 Kidney & Urinary Tract Procedures for Nonmalignancy 1.0610 4443 2 Kidney & Urinary Tract Procedures for Nonmalignancy 1.2634 4443 3 Kidney & Urinary Tract Procedures for Nonmalignancy 2.6876 4443 4 Kidney & Urinary Tract Procedures for Nonmalignancy 6.5477 4444 1 Renal Dialysis Access Device Procedure Only 0.9453 10444 2 Renal Dialysis Access Device Procedure Only 1.6815 10444 3 Renal Dialysis Access Device Procedure Only 3.1843 10444 4 Renal Dialysis Access Device Procedure Only 7.3885 10445 1 Other Bladder Procedures 0.7310 3445 2 Other Bladder Procedures 1.3083 3445 3 Other Bladder Procedures 2.0711 3445 4 Other Bladder Procedures 2.7092 3446 1 Urethral & Transurethral Procedures 0.6649 3446 2 Urethral & Transurethral Procedures 0.8380 3446 3 Urethral & Transurethral Procedures 1.7739 3446 4 Urethral & Transurethral Procedures 3.2365 3447 1 Other Kidney, Urinary Tract & Related Procedures 1.1122 7447 2 Other Kidney, Urinary Tract & Related Procedures 1.5422 7

45


ALOS

447 3 Other Kidney, Urinary Tract & Related Procedures 2.8976 7447 4 Other Kidney, Urinary Tract & Related Procedures 7.3417 7460 1 Renal Failure 0.6281 6460 2 Renal Failure 0.8416 6460 3 Renal Failure 1.2799 6460 4 Renal Failure 3.9316 6461 1 Kidney & Urinary Tract Malignancy 0.4296 7461 2 Kidney & Urinary Tract Malignancy 0.9405 7461 3 Kidney & Urinary Tract Malignancy 1.7708 7461 4 Kidney & Urinary Tract Malignancy 3.0457 7462 1 Nephritis & Nephrosis 0.4795 4462 2 Nephritis & Nephrosis 0.6416 4462 3 Nephritis & Nephrosis 1.2929 4462 4 Nephritis & Nephrosis 4.2758 4463 1 Kidney & Urinary Tract Infections 0.5392 4463 2 Kidney & Urinary Tract Infections 0.6806 4463 3 Kidney & Urinary Tract Infections 1.0618 4463 4 Kidney & Urinary Tract Infections 2.1722 4465 1 Urinary Stones & Acquired Upper Urinary Tract Obstruction 0.4371 2465 2 Urinary Stones & Acquired Upper Urinary Tract Obstruction 0.5368 2465 3 Urinary Stones & Acquired Upper Urinary Tract Obstruction 0.9553 2465 4 Urinary Stones & Acquired Upper Urinary Tract Obstruction 2.5497 2466 1 Malfunction, Reaction & Complic of Genitourinary Device Or Proc 0.4566 6466 2 Malfunction, Reaction & Complic of Genitourinary Device Or Proc 0.7179 6466 3 Malfunction, Reaction & Complic of Genitourinary Device Or Proc 1.2525 6466 4 Malfunction, Reaction & Complic of Genitourinary Device Or Proc 2.6386 6468 1 Other Kidney & Urinary Tract Diagnoses, Signs & Symptoms 0.5264 4468 2 Other Kidney & Urinary Tract Diagnoses, Signs & Symptoms 0.8173 4468 3 Other Kidney & Urinary Tract Diagnoses, Signs & Symptoms 1.2923 4468 4 Other Kidney & Urinary Tract Diagnoses, Signs & Symptoms 3.7546 4480 1 Major Male Pelvic Procedures 1.1358 2480 2 Major Male Pelvic Procedures 1.2873 2480 3 Major Male Pelvic Procedures 2.2518 2480 4 Major Male Pelvic Procedures 2.4570 2481 1 Penis Procedures 0.8245 3481 2 Penis Procedures 1.2629 3481 3 Penis Procedures 3.1817 3481 4 Penis Procedures 5.5104 3482 1 Transurethral Prostatectomy 0.5997 2482 2 Transurethral Prostatectomy 0.7789 2482 3 Transurethral Prostatectomy 1.7490 2482 4 Transurethral Prostatectomy 1.9083 2483 1 Testes & Scrotal Procedures 0.5951 2483 2 Testes & Scrotal Procedures 1.1771 2483 3 Testes & Scrotal Procedures 4.6643 2483 4 Testes & Scrotal Procedures 4.6643 2484 1 Other Male Reproductive System & Related Procedures 0.8751 3484 2 Other Male Reproductive System & Related Procedures 1.0677 3484 3 Other Male Reproductive System & Related Procedures 1.7406 3484 4 Other Male Reproductive System & Related Procedures 2.0107 3500 1 Malignancy, Male Reproductive System 0.4507 7500 2 Malignancy, Male Reproductive System 1.0412 7500 3 Malignancy, Male Reproductive System 1.8977 7500 4 Malignancy, Male Reproductive System 1.9949 7501 1 Male Reproductive System Diagnoses Except Malignancy 0.4984 4501 2 Male Reproductive System Diagnoses Except Malignancy 0.6975 4501 3 Male Reproductive System Diagnoses Except Malignancy 1.0844 4

46


ALOS

501 4 Male Reproductive System Diagnoses Except Malignancy 1.1490 4510 1 Pelvic Evisceration, Radical Hysterectectomy & Radical GYN Procs 1.2860 5510 2 Pelvic Evisceration, Radical Hysterectectomy & Radical GYN Procs 1.6034 5510 3 Pelvic Evisceration, Radical Hysterectectomy & Radical GYN Procs 3.0902 5510 4 Pelvic Evisceration, Radical Hysterectectomy & Radical GYN Procs 8.1673 5511 1 Uterine & Adnexa Procedures for Ovarian & Adnexal Malignancy 1.1904 6511 2 Uterine & Adnexa Procedures for Ovarian & Adnexal Malignancy 1.6225 6511 3 Uterine & Adnexa Procedures for Ovarian & Adnexal Malignancy 2.8445 6511 4 Uterine & Adnexa Procedures for Ovarian & Adnexal Malignancy 6.4013 6512 1 Uterine & Adnexa Procedures for Non-ovarian & Non-adnexal Malig 1.0243 4512 2 Uterine & Adnexa Procedures for Non-ovarian & Non-adnexal Malig 1.2179 4512 3 Uterine & Adnexa Procedures for Non-ovarian & Non-adnexal Malig 2.4655 4512 4 Uterine & Adnexa Procedures for Non-ovarian & Non-adnexal Malig 6.0003 4513 1 Uterine & Adnexa Procedures for Non-Malignancy Except Leiomyoma 0.8058 2513 2 Uterine & Adnexa Procedures for Non-Malignancy Except Leiomyoma 0.9889 2513 3 Uterine & Adnexa Procedures for Non-Malignancy Except Leiomyoma 1.9323 2513 4 Uterine & Adnexa Procedures for Non-Malignancy Except Leiomyoma 4.4494 2514 1 Female Reproductive System Reconstructive Procedures 0.6530 2514 2 Female Reproductive System Reconstructive Procedures 0.8780 2514 3 Female Reproductive System Reconstructive Procedures 1.2190 2514 4 Female Reproductive System Reconstructive Procedures 1.4582 2517 1 Dilation & Curettage For Non-Obstetric Procedures 0.5784 2517 2 Dilation & Curettage For Non-Obstetric Procedures 0.8265 2517 3 Dilation & Curettage For Non-Obstetric Procedures 1.8795 2517 4 Dilation & Curettage For Non-Obstetric Procedures 2.0790 2518 1 Other Female Reproductive System & Related Procedures 0.7309 3518 2 Other Female Reproductive System & Related Procedures 1.0914 3518 3 Other Female Reproductive System & Related Procedures 2.4882 3518 4 Other Female Reproductive System & Related Procedures 6.6104 3519 1 Uterine & Adnexa Procedures For Leiomyoma 0.8186 3519 2 Uterine & Adnexa Procedures For Leiomyoma 1.0190 3519 3 Uterine & Adnexa Procedures For Leiomyoma 2.0799 3519 4 Uterine & Adnexa Procedures For Leiomyoma 4.9302 3530 1 Female Reproductive System Malignancy 0.4416 7530 2 Female Reproductive System Malignancy 0.8972 7530 3 Female Reproductive System Malignancy 1.7306 7530 4 Female Reproductive System Malignancy 3.7205 7531 1 Female Reproductive System Infections 0.5660 3531 2 Female Reproductive System Infections 0.7433 3531 3 Female Reproductive System Infections 1.2446 3531 4 Female Reproductive System Infections 1.4106 3532 1 Menstrual & Other Female Reproductive System Disorders 0.5069 2532 2 Menstrual & Other Female Reproductive System Disorders 0.5766 2532 3 Menstrual & Other Female Reproductive System Disorders 1.1769 2532 4 Menstrual & Other Female Reproductive System Disorders 3.0494 2540 1 Cesarean Delivery 0.7313 4540 2 Cesarean Delivery 0.8526 4540 3 Cesarean Delivery 1.1784 4540 4 Cesarean Delivery 2.6534 4541 1 Vaginal Delivery w/ Sterilization &/or D&C 0.6873 3541 2 Vaginal Delivery w/ Sterilization &/or D&C 0.7423 3541 3 Vaginal Delivery w/ Sterilization &/or D&C 0.9788 3541 4 Vaginal Delivery w/ Sterilization &/or D&C 1.0215 3542 1 Vaginal Delivery w/ Complicating Procedures Exc Sterilization &/or D&C 0.4965 3542 2 Vaginal Delivery w/ Complicating Procedures Exc Sterilization &/or D&C 0.5460 3542 3 Vaginal Delivery w/ Complicating Procedures Exc Sterilization &/or D&C 1.2043 3542 4 Vaginal Delivery w/ Complicating Procedures Exc Sterilization &/or D&C 1.6288 3

47


ALOS

544 1 D&C, Aspiration Curettage or Hysterotomy For Obstetric Diagnoses 0.4656 2544 2 D&C, Aspiration Curettage or Hysterotomy For Obstetric Diagnoses 0.6391 2544 3 D&C, Aspiration Curettage or Hysterotomy For Obstetric Diagnoses 1.0979 2544 4 D&C, Aspiration Curettage or Hysterotomy For Obstetric Diagnoses 4.9797 2545 1 Ectopic Pregnancy Procedure 0.7328 2545 2 Ectopic Pregnancy Procedure 0.8850 2545 3 Ectopic Pregnancy Procedure 1.1624 2545 4 Ectopic Pregnancy Procedure 1.2106 2546 1 Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses 0.5098 3546 2 Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses 0.8054 3546 3 Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses 2.2436 3546 4 Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses 2.7638 3560 1 Vaginal Delivery 0.4722 2560 2 Vaginal Delivery 0.5255 2560 3 Vaginal Delivery 0.7039 2560 4 Vaginal Delivery 1.8021 2561 1 Postpartum & Post Abortion Diagnoses w/o Procedure 0.3776 3561 2 Postpartum & Post Abortion Diagnoses w/o Procedure 0.5188 3561 3 Postpartum & Post Abortion Diagnoses w/o Procedure 0.9502 3561 4 Postpartum & Post Abortion Diagnoses w/o Procedure 2.3798 3563 1 Threatened Abortion 0.3687 3563 2 Threatened Abortion 0.4901 3563 3 Threatened Abortion 0.9681 3563 4 Threatened Abortion 0.9793 3564 1 Abortion w/o D&C, Aspiration Curettage or Hysterotomy 0.3671 2564 2 Abortion w/o D&C, Aspiration Curettage or Hysterotomy 0.4336 2564 3 Abortion w/o D&C, Aspiration Curettage or Hysterotomy 0.6604 2564 4 Abortion w/o D&C, Aspiration Curettage or Hysterotomy 0.6847 2565 1 False Labor 0.2285 1565 2 False Labor 0.3575 1565 3 False Labor 0.3543 1565 4 False Labor 0.3543 1566 1 Other Antepartum Diagnoses 0.3457 3566 2 Other Antepartum Diagnoses 0.4626 3566 3 Other Antepartum Diagnoses 0.7839 3566 4 Other Antepartum Diagnoses 2.1619 3580 1 Neonate, Transferred <5 Days Old, Not Born Here 0.3849 2580 2 Neonate, Transferred <5 Days Old, Not Born Here 0.4950 2580 3 Neonate, Transferred <5 Days Old, Not Born Here 0.7440 2580 4 Neonate, Transferred <5 Days Old, Not Born Here 1.1648 2581 1 Neonate, Transferred <5 Days Old, Born Here 0.1611 1581 2 Neonate, Transferred <5 Days Old, Born Here 0.1860 1581 3 Neonate, Transferred <5 Days Old, Born Here 0.2385 1581 4 Neonate, Transferred <5 Days Old, Born Here 0.4224 1583 1 Neonate, w/ ECMO 10.7965 34583 2 Neonate, w/ ECMO 10.7965 34583 3 Neonate, w/ ECMO 10.4574 34583 4 Neonate, w/ ECMO 26.3383 34588 1 Neonate BWT <1500G W Major Procedure 18.0256 93588 2 Neonate BWT <1500G W Major Procedure 18.0256 93588 3 Neonate BWT <1500G W Major Procedure 18.0731 93588 4 Neonate BWT <1500G W Major Procedure 25.0773 93589 1 Neonate BWT < 500G 0.1397 7589 2 Neonate BWT < 500G 0.2242 7589 3 Neonate BWT < 500G 0.5416 7589 4 Neonate BWT < 500G 10.9250 7591 1 Neonate, Birthwt 500-749G w/o Major Procedure 0.1395 51

48


ALOS

591 2 Neonate, Birthwt 500-749G w/o Major Procedure 0.5373 51591 3 Neonate, Birthwt 500-749G w/o Major Procedure 8.7909 51591 4 Neonate, Birthwt 500-749G w/o Major Procedure 16.8085 51593 1 Neonate, Birthwt 750-999G w/o Major Procedure 7.9584 65593 2 Neonate, Birthwt 750-999G w/o Major Procedure 8.6990 65593 3 Neonate, Birthwt 750-999G w/o Major Procedure 12.7784 65593 4 Neonate, Birthwt 750-999G w/o Major Procedure 16.6335 65602 1 Neonate, Birthwt 1000-1249G w/ Resp Dist Synd/Oth Maj Resp Or Maj Anom 5.5247 52602 2 Neonate, Birthwt 1000-1249G w/ Resp Dist Synd/Oth Maj Resp Or Maj Anom 7.9933 52602 3 Neonate, Birthwt 1000-1249G w/ Resp Dist Synd/Oth Maj Resp Or Maj Anom 10.2897 52602 4 Neonate, Birthwt 1000-1249G w/ Resp Dist Synd/Oth Maj Resp Or Maj Anom 12.4805 52603 1 Neonate, Birthwt 1000-1249G W OR W/O Other Significant Condition 3.9165 40603 2 Neonate, Birthwt 1000-1249G W OR W/O Other Significant Condition 7.1055 40603 3 Neonate, Birthwt 1000-1249G W OR W/O Other Significant Condition 9.0676 40603 4 Neonate, Birthwt 1000-1249G W OR W/O Other Significant Condition 13.1476 40607 1 Neonate, BWT 1250-1499G W Resp Dist Synd/Oth Maj Resp Or Maj Anom 4.9863 39607 2 Neonate, BWT 1250-1499G W Resp Dist Synd/Oth Maj Resp Or Maj Anom 6.3557 39607 3 Neonate, BWT 1250-1499G W Resp Dist Synd/Oth Maj Resp Or Maj Anom 8.1553 39607 4 Neonate, BWT 1250-1499G W Resp Dist Synd/Oth Maj Resp Or Maj Anom 9.9184 39608 1 Neonate, Birthwt 1250-1499G W OR W/O Other Significant Condition 3.8235 29608 2 Neonate, Birthwt 1250-1499G W OR W/O Other Significant Condition 5.3856 29608 3 Neonate, Birthwt 1250-1499G W OR W/O Other Significant Condition 7.1935 29608 4 Neonate, Birthwt 1250-1499G W OR W/O Other Significant Condition 10.2332 29609 1 Neonate, BWT 1500-2499G W Major Procedure 5.1723 41609 2 Neonate, BWT 1500-2499G W Major Procedure 5.3334 41609 3 Neonate, BWT 1500-2499G W Major Procedure 7.1175 41609 4 Neonate, BWT 1500-2499G W Major Procedure 13.4867 41611 1 Neonate, Birthwt 1500-1999G W Major Anomaly 2.5130 24611 2 Neonate, Birthwt 1500-1999G W Major Anomaly 3.8567 24611 3 Neonate, Birthwt 1500-1999G W Major Anomaly 5.5724 24611 4 Neonate, Birthwt 1500-1999G W Major Anomaly 8.0198 24612 1 Neonate, BWT 1500-1999G W Resp Dist Synd/Oth Maj Resp Cond 3.0494 24612 2 Neonate, BWT 1500-1999G W Resp Dist Synd/Oth Maj Resp Cond 4.0463 24612 3 Neonate, BWT 1500-1999G W Resp Dist Synd/Oth Maj Resp Cond 5.5368 24612 4 Neonate, BWT 1500-1999G W Resp Dist Synd/Oth Maj Resp Cond 7.1954 24613 1 Neonate, Birthwt 1500-1999G W Congenital/Perinatal Infection 2.5886 18613 2 Neonate, Birthwt 1500-1999G W Congenital/Perinatal Infection 4.1566 18613 3 Neonate, Birthwt 1500-1999G W Congenital/Perinatal Infection 5.3212 18613 4 Neonate, Birthwt 1500-1999G W Congenital/Perinatal Infection 5.8620 18614 1 Neonate, Birthwt 1500-1999G W OR W/O Other Significant Condition 1.8146 14614 2 Neonate, Birthwt 1500-1999G W OR W/O Other Significant Condition 3.1999 14614 3 Neonate, Birthwt 1500-1999G W OR W/O Other Significant Condition 4.2572 14614 4 Neonate, Birthwt 1500-1999G W OR W/O Other Significant Condition 4.4897 14621 1 Neonate, BWT 2000-2499G W Major Anomaly 1.1751 13621 2 Neonate, BWT 2000-2499G W Major Anomaly 2.3928 13621 3 Neonate, BWT 2000-2499G W Major Anomaly 3.4126 13621 4 Neonate, BWT 2000-2499G W Major Anomaly 5.5108 13622 1 Neonate, BWT 2000-2499G W Resp Dist Synd/Oth Maj Resp Cond 1.7188 13622 2 Neonate, BWT 2000-2499G W Resp Dist Synd/Oth Maj Resp Cond 2.2542 13622 3 Neonate, BWT 2000-2499G W Resp Dist Synd/Oth Maj Resp Cond 3.2015 13622 4 Neonate, BWT 2000-2499G W Resp Dist Synd/Oth Maj Resp Cond 4.9392 13623 1 Neonate, Birthwt 2000-2499G W Congenital/Perinatal Infection 1.4045 10623 2 Neonate, Birthwt 2000-2499G W Congenital/Perinatal Infection 2.5566 10623 3 Neonate, Birthwt 2000-2499G W Congenital/Perinatal Infection 3.2233 10623 4 Neonate, Birthwt 2000-2499G W Congenital/Perinatal Infection 3.3975 10625 1 Neonate, Birthwt 2000-2499G W Other Significant Condition 1.5583 11625 2 Neonate, Birthwt 2000-2499G W Other Significant Condition 2.6287 11

49


ALOS

625 3 Neonate, Birthwt 2000-2499G W Other Significant Condition 3.1972 11625 4 Neonate, Birthwt 2000-2499G W Other Significant Condition 3.4399 11626 1 Neonate, BWT 2000-2499G, Normal Newborn Or Neonate W Other Problem 0.2396 5626 2 Neonate, BWT 2000-2499G, Normal Newborn Or Neonate W Other Problem 0.6289 5626 3 Neonate, BWT 2000-2499G, Normal Newborn Or Neonate W Other Problem 1.2716 5626 4 Neonate, BWT 2000-2499G, Normal Newborn Or Neonate W Other Problem 1.2728 5630 1 Neonate, Birthwt > 2499g w/ Major Cardiovasc Procedure 3.1583 26630 2 Neonate, Birthwt > 2499g w/ Major Cardiovasc Procedure 3.5449 26630 3 Neonate, Birthwt > 2499g w/ Major Cardiovasc Procedure 5.7415 26630 4 Neonate, Birthwt > 2499g w/ Major Cardiovasc Procedure 12.9632 26631 1 Neonate, Birthwt > 2499g w/ Other Major Procedure 1.6267 29631 2 Neonate, Birthwt > 2499g w/ Other Major Procedure 3.0993 29631 3 Neonate, Birthwt > 2499g w/ Other Major Procedure 6.2800 29631 4 Neonate, Birthwt > 2499g w/ Other Major Procedure 13.9419 29633 1 Neonate, Birthwt > 2499g w/ Major Anomaly 0.3080 6633 2 Neonate, Birthwt > 2499g w/ Major Anomaly 0.9437 6633 3 Neonate, Birthwt > 2499g w/ Major Anomaly 2.3922 6633 4 Neonate, Birthwt > 2499g w/ Major Anomaly 6.4536 6634 1 Neonate, Birthwt > 2499g W Resp Dist Synd/Oth Maj Resp Cond 0.7969 8634 2 Neonate, Birthwt > 2499g W Resp Dist Synd/Oth Maj Resp Cond 1.3131 8634 3 Neonate, Birthwt > 2499g W Resp Dist Synd/Oth Maj Resp Cond 2.1720 8634 4 Neonate, Birthwt > 2499g W Resp Dist Synd/Oth Maj Resp Cond 4.7748 8636 1 Neonate, Birthwt > 2499g W Congenital/Perinatal Infection 0.8477 6636 2 Neonate, Birthwt > 2499g W Congenital/Perinatal Infection 1.2943 6636 3 Neonate, Birthwt > 2499g W Congenital/Perinatal Infection 2.5084 6636 4 Neonate, Birthwt > 2499g W Congenital/Perinatal Infection 5.7909 6639 1 Neonate, Birthwt > 2499g W Other Significant Condition 0.5146 5639 2 Neonate, Birthwt > 2499g W Other Significant Condition 1.2735 5639 3 Neonate, Birthwt > 2499g W Other Significant Condition 2.1057 5639 4 Neonate, Birthwt > 2499g W Other Significant Condition 4.7600 5640 1 Neonate, Bwt > 2499g, Normal Newborn Or Neonate W Other Problem 0.1773 2640 2 Neonate, Bwt > 2499g, Normal Newborn Or Neonate W Other Problem 0.2767 2640 3 Neonate, Bwt > 2499g, Normal Newborn Or Neonate W Other Problem 0.5998 2640 4 Neonate, Bwt > 2499g, Normal Newborn Or Neonate W Other Problem 0.6001 2650 1 Splenectomy 1.2861 6650 2 Splenectomy 1.9765 6650 3 Splenectomy 2.8202 6650 4 Splenectomy 9.6691 6651 1 Other Procedures of Blood & Blood Forming Organs 1.0121 5651 2 Other Procedures of Blood & Blood Forming Organs 1.5675 5651 3 Other Procedures of Blood & Blood Forming Organs 2.6230 5651 4 Other Procedures of Blood & Blood Forming Organs 8.1096 5660 1 Major Hematologic/Immunologic Diag Exc Sickle Cell Crisis & Coagul 0.7193 6660 2 Major Hematologic/Immunologic Diag Exc Sickle Cell Crisis & Coagul 1.0378 6660 3 Major Hematologic/Immunologic Diag Exc Sickle Cell Crisis & Coagul 1.9937 6660 4 Major Hematologic/Immunologic Diag Exc Sickle Cell Crisis & Coagul 7.2697 6661 1 Coagulation & Platelet Disorders 0.8353 4661 2 Coagulation & Platelet Disorders 1.1664 4661 3 Coagulation & Platelet Disorders 1.9036 4661 4 Coagulation & Platelet Disorders 6.0895 4662 1 Sickle Cell Anemia Crisis 0.7203 5662 2 Sickle Cell Anemia Crisis 1.0260 5662 3 Sickle Cell Anemia Crisis 1.6071 5662 4 Sickle Cell Anemia Crisis 3.7472 5663 1 Other Anemia & Disorders Of Blood & Blood Forming Organs 0.5507 3663 2 Other Anemia & Disorders Of Blood & Blood Forming Organs 0.7591 3663 3 Other Anemia & Disorders Of Blood & Blood Forming Organs 1.2126 3

50


ALOS

663 4 Other Anemia & Disorders Of Blood & Blood Forming Organs 2.6971 3680 1 Major O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 1.5058 12680 2 Major O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 2.4476 12680 3 Major O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 4.6679 12680 4 Major O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 11.8606 12681 1 Other O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 1.0205 7681 2 Other O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 1.6797 7681 3 Other O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 3.9718 7681 4 Other O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 9.2095 7690 1 Acute Leukemia 1.4815 20690 2 Acute Leukemia 3.4536 20690 3 Acute Leukemia 6.5528 20690 4 Acute Leukemia 10.6125 20691 1 Lymphoma & Non-acute Leukemia 1.0162 9691 2 Lymphoma & Non-acute Leukemia 1.4815 9691 3 Lymphoma & Non-acute Leukemia 2.8467 9691 4 Lymphoma & Non-acute Leukemia 6.3235 9692 1 Radiotherapy 0.7819 4692 2 Radiotherapy 1.4531 4692 3 Radiotherapy 3.3182 4692 4 Radiotherapy 3.7445 4693 1 Chemotherapy 0.6750 4693 2 Chemotherapy 0.9199 4693 3 Chemotherapy 2.0823 4693 4 Chemotherapy 7.7590 4694 1 Lymphatic & Other Malignancies & Neoplasms Of Uncertain Behavior 0.6231 7694 2 Lymphatic & Other Malignancies & Neoplasms Of Uncertain Behavior 1.0692 7694 3 Lymphatic & Other Malignancies & Neoplasms Of Uncertain Behavior 1.9439 7694 4 Lymphatic & Other Malignancies & Neoplasms Of Uncertain Behavior 3.7877 7710 1 Infectious & Parasitic Diseases Including HIV W O.R. Procedure 1.1751 20710 2 Infectious & Parasitic Diseases Including HIV W O.R. Procedure 2.2299 20710 3 Infectious & Parasitic Diseases Including HIV W O.R. Procedure 3.7439 20710 4 Infectious & Parasitic Diseases Including HIV W O.R. Procedure 8.3039 20711 1 Post-Op,Post-Trauma, Other Device Infections W O.R. Procedure 1.2976 10711 2 Post-Op,Post-Trauma, Other Device Infections W O.R. Procedure 1.9147 10711 3 Post-Op,Post-Trauma, Other Device Infections W O.R. Procedure 3.5800 10711 4 Post-Op,Post-Trauma, Other Device Infections W O.R. Procedure 8.6200 10720 1 Septicemia & Disseminated Infections 0.7281 9720 2 Septicemia & Disseminated Infections 1.1057 9720 3 Septicemia & Disseminated Infections 1.7498 9720 4 Septicemia & Disseminated Infections 3.5319 9721 1 Post-Operative, Post-Traumatic, Other Device Infections 0.7252 5721 2 Post-Operative, Post-Traumatic, Other Device Infections 0.9865 5721 3 Post-Operative, Post-Traumatic, Other Device Infections 1.6286 5721 4 Post-Operative, Post-Traumatic, Other Device Infections 3.6589 5722 1 Fever 0.4729 3722 2 Fever 0.6615 3722 3 Fever 0.9978 3722 4 Fever 1.8496 3723 1 Viral Illness 0.4562 3723 2 Viral Illness 0.5633 3723 3 Viral Illness 0.9085 3723 4 Viral Illness 3.1048 3724 1 Other Infectious & Parasitic Diseases 0.6923 5724 2 Other Infectious & Parasitic Diseases 0.8680 5724 3 Other Infectious & Parasitic Diseases 1.5310 5724 4 Other Infectious & Parasitic Diseases 3.4362 5

51


ALOS

740 1 Mental Illness Diagnosis W O.R. Procedure 1.9111 20740 2 Mental Illness Diagnosis W O.R. Procedure 2.9854 20740 3 Mental Illness Diagnosis W O.R. Procedure 5.6270 20740 4 Mental Illness Diagnosis W O.R. Procedure 5.4497 20750 1 Schizophrenia 1.0551 7750 2 Schizophrenia 0.9860 7750 3 Schizophrenia 0.9579 7750 4 Schizophrenia 0.9579 7751 1 Major Depressive Disorders & Other/Unspecified Psychoses 0.6794 6751 2 Major Depressive Disorders & Other/Unspecified Psychoses 0.9153 6751 3 Major Depressive Disorders & Other/Unspecified Psychoses 1.1309 6751 4 Major Depressive Disorders & Other/Unspecified Psychoses 1.1878 6752 1 Disorders of Personality & Impulse Control 0.8369 6752 2 Disorders of Personality & Impulse Control 0.8369 6752 3 Disorders of Personality & Impulse Control 0.8369 6752 4 Disorders of Personality & Impulse Control 0.8369 6753 1 Bipolar Disorders 0.7779 5753 2 Bipolar Disorders 0.7954 5753 3 Bipolar Disorders 0.7852 5753 4 Bipolar Disorders 0.7852 5754 1 Depression Except Major Depressive Disorder 0.5112 3754 2 Depression Except Major Depressive Disorder 0.5310 3754 3 Depression Except Major Depressive Disorder 0.5516 3754 4 Depression Except Major Depressive Disorder 0.5516 3755 1 Adjustment Disorders & Neuroses Except Depressive Diagnoses 0.4019 3755 2 Adjustment Disorders & Neuroses Except Depressive Diagnoses 0.6678 3755 3 Adjustment Disorders & Neuroses Except Depressive Diagnoses 0.6935 3755 4 Adjustment Disorders & Neuroses Except Depressive Diagnoses 0.6935 3756 1 Acute Anxiety & Delirium States 0.4625 2756 2 Acute Anxiety & Delirium States 0.6724 2756 3 Acute Anxiety & Delirium States 0.7732 2756 4 Acute Anxiety & Delirium States 0.8819 2757 1 Organic Mental Health Disturbances 0.9163 8757 2 Organic Mental Health Disturbances 1.1354 8757 3 Organic Mental Health Disturbances 1.3485 8757 4 Organic Mental Health Disturbances 1.4112 8758 1 Childhood Behavioral Disorders 0.5634 3758 2 Childhood Behavioral Disorders 0.5588 3758 3 Childhood Behavioral Disorders 0.6095 3758 4 Childhood Behavioral Disorders 0.6095 3759 1 Eating Disorders 1.8232 16759 2 Eating Disorders 1.5407 16759 3 Eating Disorders 2.0329 16759 4 Eating Disorders 2.2941 16760 1 Other Mental Health Disorders 0.4640 3760 2 Other Mental Health Disorders 0.7282 3760 3 Other Mental Health Disorders 0.8321 3760 4 Other Mental Health Disorders 0.8321 3770 1 Drug & Alcohol Abuse or Dependence, Left Against Medical Advice 0.3735 3770 2 Drug & Alcohol Abuse or Dependence, Left Against Medical Advice 0.3969 3770 3 Drug & Alcohol Abuse or Dependence, Left Against Medical Advice 0.5891 3770 4 Drug & Alcohol Abuse or Dependence, Left Against Medical Advice 0.6651 3772 1 Alcohol & Drug Dependence w/ Rehab/Detox Therapy 1.2486 19772 2 Alcohol & Drug Dependence w/ Rehab/Detox Therapy 1.3761 19772 3 Alcohol & Drug Dependence w/ Rehab/Detox Therapy 1.7133 19772 4 Alcohol & Drug Dependence w/ Rehab/Detox Therapy 1.7133 19773 1 Opioid Abuse & Dependence 0.5284 5

52


ALOS

773 2 Opioid Abuse & Dependence 0.6281 5773 3 Opioid Abuse & Dependence 0.7893 5773 4 Opioid Abuse & Dependence 0.8374 5774 1 Cocaine Abuse & Dependence 0.6549 6774 2 Cocaine Abuse & Dependence 0.6195 6774 3 Cocaine Abuse & Dependence 0.7327 6774 4 Cocaine Abuse & Dependence 0.7714 6775 1 Alcohol Abuse & Dependence 0.4995 4775 2 Alcohol Abuse & Dependence 0.6631 4775 3 Alcohol Abuse & Dependence 1.1452 4775 4 Alcohol Abuse & Dependence 3.4083 4776 1 Other Drug Abuse & Dependence 0.6760 9776 2 Other Drug Abuse & Dependence 0.6962 9776 3 Other Drug Abuse & Dependence 1.0442 9776 4 Other Drug Abuse & Dependence 1.1048 9791 1 O.R. Procedure For Other Complications Of Treatment 0.8276 5791 2 O.R. Procedure For Other Complications Of Treatment 1.4863 5791 3 O.R. Procedure For Other Complications Of Treatment 2.6602 5791 4 O.R. Procedure For Other Complications Of Treatment 7.2751 5811 1 Allergic Reactions 0.3087 2811 2 Allergic Reactions 0.4418 2811 3 Allergic Reactions 0.9852 2811 4 Allergic Reactions 1.9579 2812 1 Poisoning Of Medicinal Agents 0.4218 3812 2 Poisoning Of Medicinal Agents 0.5229 3812 3 Poisoning Of Medicinal Agents 0.9702 3812 4 Poisoning Of Medicinal Agents 2.7055 3813 1 Other Complications of Treatment 0.4969 3813 2 Other Complications of Treatment 0.7318 3813 3 Other Complications of Treatment 1.2327 3813 4 Other Complications of Treatment 2.4367 3815 1 Other Injury, Poisoning & Toxic Effect Diagnoses 0.3947 3815 2 Other Injury, Poisoning & Toxic Effect Diagnoses 0.5780 3815 3 Other Injury, Poisoning & Toxic Effect Diagnoses 1.2818 3815 4 Other Injury, Poisoning & Toxic Effect Diagnoses 3.2640 3816 1 Toxic Effects Of Non-Medicinal Substances 0.3934 3816 2 Toxic Effects Of Non-Medicinal Substances 0.5375 3816 3 Toxic Effects Of Non-Medicinal Substances 0.9534 3816 4 Toxic Effects Of Non-Medicinal Substances 2.8562 3841 1 Extensive 3rd Degree Burns W Skin Graft 10.6290 35841 2 Extensive 3rd Degree Burns W Skin Graft 10.6290 35841 3 Extensive 3rd Degree Burns W Skin Graft 10.2188 35841 4 Extensive 3rd Degree Burns W Skin Graft 19.7152 35842 1 Full Thickness Burns W Skin Graft 2.1699 13842 2 Full Thickness Burns W Skin Graft 3.9566 13842 3 Full Thickness Burns W Skin Graft 5.8471 13842 4 Full Thickness Burns W Skin Graft 11.4209 13843 1 Extensive 3rd Degree Or Full Thickness Burns W/O Skin Graft 0.8603 7843 2 Extensive 3rd Degree Or Full Thickness Burns W/O Skin Graft 1.5132 7843 3 Extensive 3rd Degree Or Full Thickness Burns W/O Skin Graft 2.6614 7843 4 Extensive 3rd Degree Or Full Thickness Burns W/O Skin Graft 2.8571 7844 1 Partial Thickness Burns W Or W/O Skin Graft 0.5713 5844 2 Partial Thickness Burns W Or W/O Skin Graft 2.0139 5844 3 Partial Thickness Burns W Or W/O Skin Graft 3.2766 5844 4 Partial Thickness Burns W Or W/O Skin Graft 13.0314 5850 1 Procedure W Diag Of Rehab, Aftercare Or Oth Contact W Health Service 1.1487 9850 2 Procedure W Diag Of Rehab, Aftercare Or Oth Contact W Health Service 1.6225 9

53


ALOS

850 3 Procedure W Diag Of Rehab, Aftercare Or Oth Contact W Health Service 4.5928 9850 4 Procedure W Diag Of Rehab, Aftercare Or Oth Contact W Health Service 12.7111 9860 1 Rehabilitation 1.4245 17860 2 Rehabilitation 1.3844 17860 3 Rehabilitation 3.1930 17860 4 Rehabilitation 6.7044 17861 1 Signs, Symptoms & Other Factors Influencing Health Status 0.4069 3861 2 Signs, Symptoms & Other Factors Influencing Health Status 0.6131 3861 3 Signs, Symptoms & Other Factors Influencing Health Status 1.0724 3861 4 Signs, Symptoms & Other Factors Influencing Health Status 2.0735 3862 1 Other Aftercare & Convalescence 0.5472 3862 2 Other Aftercare & Convalescence 0.6066 3862 3 Other Aftercare & Convalescence 1.3638 3862 4 Other Aftercare & Convalescence 1.7120 3863 1 Neonatal Aftercare 0.8439 15863 2 Neonatal Aftercare 1.9507 15863 3 Neonatal Aftercare 3.1923 15863 4 Neonatal Aftercare 4.2683 15890 1 HIV W Multiple Major HIV Related Conditions 1.4695 16890 2 HIV W Multiple Major HIV Related Conditions 1.4695 16890 3 HIV W Multiple Major HIV Related Conditions 2.5041 16890 4 HIV W Multiple Major HIV Related Conditions 4.9023 16892 1 HIV W Major HIV Related Condition 1.3793 9892 2 HIV W Major HIV Related Condition 1.1604 9892 3 HIV W Major HIV Related Condition 1.5987 9892 4 HIV W Major HIV Related Condition 3.3342 9893 1 HIV W Multiple Significant HIV Related Conditions 1.1159 7893 2 HIV W Multiple Significant HIV Related Conditions 1.1886 7893 3 HIV W Multiple Significant HIV Related Conditions 1.6843 7893 4 HIV W Multiple Significant HIV Related Conditions 1.6976 7894 1 HIV W One Signif HIV Cond Or W/O Signif Related Cond 0.5960 5894 2 HIV W One Signif HIV Cond Or W/O Signif Related Cond 0.8005 5894 3 HIV W One Signif HIV Cond Or W/O Signif Related Cond 1.2066 5894 4 HIV W One Signif HIV Cond Or W/O Signif Related Cond 2.6615 5910 1 Craniotomy For Multiple Significant Trauma 4.1355 16910 2 Craniotomy For Multiple Significant Trauma 4.1355 16910 3 Craniotomy For Multiple Significant Trauma 4.4950 16910 4 Craniotomy For Multiple Significant Trauma 8.1233 16911 1 Extensive Abdominal/Thoraic Procedures For Mult Significant Trauma 2.1815 13911 2 Extensive Abdominal/Thoraic Procedures For Mult Significant Trauma 2.1960 13911 3 Extensive Abdominal/Thoraic Procedures For Mult Significant Trauma 3.0091 13911 4 Extensive Abdominal/Thoraic Procedures For Mult Significant Trauma 6.1066 13912 1 Musculoskeletal & Other Procedures For Multiple Significant Trauma 2.4145 13912 2 Musculoskeletal & Other Procedures For Multiple Significant Trauma 2.4087 13912 3 Musculoskeletal & Other Procedures For Multiple Significant Trauma 4.7898 13912 4 Musculoskeletal & Other Procedures For Multiple Significant Trauma 9.1597 13930 1 Multiple Significant Trauma W/O O.R. Procedure 0.8270 7930 2 Multiple Significant Trauma W/O O.R. Procedure 1.1342 7930 3 Multiple Significant Trauma W/O O.R. Procedure 1.9425 7930 4 Multiple Significant Trauma W/O O.R. Procedure 4.6618 7950 1 Extensive Procedure Unrelated To Principal Diagnosis 1.3453 13950 2 Extensive Procedure Unrelated To Principal Diagnosis 2.4610 13950 3 Extensive Procedure Unrelated To Principal Diagnosis 4.8762 13950 4 Extensive Procedure Unrelated To Principal Diagnosis 9.5687 13951 1 Moderately Extensive Procedure Unrelated To Principal Diagnosis 0.9368 8951 2 Moderately Extensive Procedure Unrelated To Principal Diagnosis 1.5545 8951 3 Moderately Extensive Procedure Unrelated To Principal Diagnosis 3.3437 8

54


ALOS

951 4 Moderately Extensive Procedure Unrelated To Principal Diagnosis 6.9754 8952 1 Nonextensive Procedure Unrelated To Principal Diagnosis 0.8129 7952 2 Nonextensive Procedure Unrelated To Principal Diagnosis 1.3494 7952 3 Nonextensive Procedure Unrelated To Principal Diagnosis 2.7947 7952 4 Nonextensive Procedure Unrelated To Principal Diagnosis 6.2612 7

55

APR-DRG APR-DRG Description

2009 High Cost Outlier Thresholds Effective 12/1/09

2010 High Cost Outlier Thresholds

Effective 1/1/10 001 Liver Transplant 632,417$ 643,168$ 002 Heart &/or Lung Transplant 1,328,568$ 1,351,154$ 003 Bone Marrow Transplant 531,628$ 540,666$ 004 Tracheostomy W Long Term Mechanical Ventilation W Extensive Procedure 965,288$ 981,698$ 005 Tracheostomy W Long Term Mechanical Ventilation W/O Extensive Procedure 649,358$ 660,397$ 006 Pancreas Transplant 325,730$ 331,267$ 020 Craniotomy for Trauma 164,112$ 166,902$ 021 Craniotomy Except for Trauma 181,388$ 184,472$ 022 Ventricular Shunt Procedures 95,683$ 97,310$ 023 Spinal Procedures 120,713$ 122,765$ 024 Extracranial Vascular Procedures 90,435$ 91,972$ 026 Other Nervous System & Related Procedures 102,040$ 103,775$ 040 Spinal Disorders & Injuries 72,211$ 73,439$ 041 Nervous System Malignancy 76,357$ 77,655$ 042 Degenerative Nervous System Disorders Exc Mult Sclerosis 67,799$ 68,952$ 043 Multiple Sclerosis & Other Demyelinating Diseases 42,221$ 42,939$ 044 Intracranial Hemorrhage 103,759$ 105,523$ 045 CVA & Precerebral Occulusion w/ Infarct 55,435$ 56,377$ 046 Nonspecific CVA & Precerebral Occlusion w/o Infarct 42,630$ 43,355$ 047 Transient Ischemia 23,797$ 24,202$ 048 Peripheral, Cranial & Autonomic Nerve Disorders 40,095$ 40,777$ 049 Bacterial & Tuberculous Infections of Nervous System 126,954$ 129,112$ 050 Non-bacterial Infections of Nervous System Exc Viral Meningitis 99,215$ 100,902$ 051 Viral Meningitis 31,949$ 32,492$ 052 Nontraumatic Stupor & Coma 48,171$ 48,990$ 053 Seizure 31,048$ 31,576$ 054 Migraine & Other Headaches 24,485$ 24,901$ 055 Head Trauma w/ Coma > 1 Hr or Hemorrhage 54,351$ 55,275$ 056 Brain Contusion/Laceration & Compliated Skull FX, COMA < 1 HR OR No Coma 46,345$ 47,133$ 057 Concussion, Closed Skull FX Nos, Uncomplicated Intracranial Injury, Coma <1 Hr or No Coma 20,296$ 20,641$ 058 Other Disorders of Nervous System 39,041$ 39,705$ 070 Orbital Procedures 46,429$ 47,218$ 073 Eye Procedures Except Orbit 36,133$ 36,747$ 080 Acute Major Eye Infections 28,610$ 29,096$ 082 Eye Disorders Except Major Infections 28,515$ 29,000$ 089 Major Cranial/Facial Bone Procedures 103,812$ 105,577$ 090 Major Larynx & Trachea Procedures 159,811$ 162,528$ 091 Other Major Head & Neck Procedures 184,507$ 187,644$ 092 Facial Bone Procedures Except Major Cranial/Facial Bone Procedures 51,207$ 52,078$ 093 Sinus & Mastoid Procedures 45,034$ 45,800$ 095 Cleft Lip & Palate Repair 34,657$ 35,246$ 097 Tonsill & Adenoid Procedures 28,234$ 28,714$ 098 Other Ear, Nose, Mouth & Throat Procedures 37,361$ 37,996$ 110 Ear, Nose, Mouth Throat, Cranial/Facial Malignancies 73,550$ 74,800$ 111 Vertigo & Other Labyrinth Disorders 21,525$ 21,891$ 113 Infections Of The Upper Respiratory Tract 19,824$ 20,161$ 114 Dental & Oral Diseases & Injuries 30,574$ 31,094$ 115 Other Ear, Nose, Mouth,Throat & Cranial/Facial Diagnoses 26,755$ 27,210$ 120 Major Respiratory & Chest Procedures 111,067$ 112,955$ 121 Other Respiratory & Chest Procedures 95,174$ 96,792$ 130 Respiratory System Diagnosis w/ Ventilator Support 96+ Hours 243,053$ 247,185$

Cost Outlier Thresholds

56




Effective 1/1/10

131 Cystic Fibrosis - Pulmonary Disease 92,839$ 94,417$ 132 BPD & Oth Chronic Respiratory Dis Arising In Perinatal Period 89,709$ 91,234$ 133 Pulmonary Edema & Respiratory Failure 78,887$ 80,228$ 134 Pulmonary Embolism 51,842$ 52,723$ 135 Major Chest & Respiratory Trauma 37,685$ 38,326$ 136 Respiratory Malignancy 84,922$ 86,366$ 137 Major Respiratory Infections & Inflammations 79,872$ 81,230$ 138 Bronchiolitis & RSV Pneumonia 25,704$ 26,141$ 139 Other Pneumonia 32,873$ 33,432$ 140 Chronic Obstructive Pulmonary Disease 34,154$ 34,735$ 141 Asthma 23,474$ 23,873$ 142 Interstitial Lung Disease 56,614$ 57,576$ 143 Other Respiratory Diagnosis Except Signs, Symptoms & Minor Diagnoses 45,725$ 46,502$ 144 Respiratory System Signs, Symptoms & Other Diagnoses 25,740$ 26,178$ 160 Major Cardiothoracic Repair of Heart Anomaly 270,150$ 274,743$ 161 Cardiac Defibrillator & Heart Assist Anomaly 238,407$ 242,460$ 162 Cardiac Valve Procedures w/ Cardiac Catheterization 266,063$ 270,586$ 163 Cardiac Valve Procedures w/o Cardiac Catheterization 176,411$ 179,410$ 165 Coronary Bypass w/ Cardiac Cath Or Percutaneous Cardiac Procedure 180,517$ 183,586$ 166 Coronary Bypass w/o Cardiac Cath Or Percutaneous Cardiac Procedure 133,055$ 135,317$ 167 Other Cardiothoracic Procedures 163,863$ 166,649$ 169 Major Thoracic & Abdominal Vascular Procedures 180,372$ 183,438$ 170 Permanent Cardiac Pacemaker Implant w/ AMI, Heart Failure or Shock 174,349$ 177,313$ 171 Perm Cardiac Pacemaker Implant w/o AMI, Heart Failure or Shock 91,012$ 92,559$ 173 Other Vascular Procedures 117,406$ 119,402$ 174 Percutaneous Cardiovascular Procedures w/ AMI 85,886$ 87,346$ 175 Percutaneous Cardiovascular Procedures w/o AMI 62,795$ 63,863$ 176 Cardiac Pacemaker & Defibrillator Device Replacement 145,243$ 147,712$ 177 Cardiac Pacemaker & Defibrillator Revision Except Device Replacement 109,839$ 111,706$ 180 Other Circulatory System Procedures 143,747$ 146,191$ 190 Acute Myocardial Infarction 62,189$ 63,246$ 191 Cardiac Catheterization w/ Circ Disord Exc Ischemic Heart Disease 63,184$ 64,258$ 192 Cardiac Catheterization for Ischemic Heart Disease 33,064$ 33,626$ 193 Acute & Subacute Endocarditis 131,145$ 133,374$ 194 Heart Failure 45,833$ 46,612$ 196 Cardiac Arrest 69,077$ 70,251$ 197 Peripheral & Other Vascular Disorders 45,486$ 46,259$ 198 Angina Pectoris & Coronary Atherosclerosis 20,584$ 20,934$ 199 Hypertension 23,750$ 24,154$ 200 Cardiac Congenital & Valvular Disorders 43,152$ 43,886$ 201 Cardiac Arrhythmia & Conduction Disorders 26,444$ 26,894$ 203 Chest Pain 16,243$ 16,519$ 204 Syncope & Collapse 23,198$ 23,592$ 205 Cardiomyopathy 33,763$ 34,337$ 206 Malfunction, Reaction & Comp of Cardiac or Vasc Device or Proc 83,814$ 85,239$ 207 Other Circulatory System Diagnoses 36,459$ 37,079$ 220 Major Stomach, Esophageal & Duodenal Procedures 139,311$ 141,679$ 221 Major Small & Large Bowel Procedures 87,113$ 88,594$ 222 Minor Stomach, Esophageal & Duodenal Procedures 37,985$ 38,631$ 223 Minor Small & Large Bowel Procedures 61,759$ 62,809$ 224 Peritoneal Adhesiolysis 67,875$ 69,029$ 225 Appendectomy 28,500$ 28,985$ 226 Anal Procedures 28,415$ 28,898$

57




Effective 1/1/10

227 Hernia Procedures Except Inguinal, Femoral & Umbilical 44,118$ 44,868$ 228 Inguinal, Femoral & Umbilical Hernia Procedures 29,930$ 30,439$ 229 Other Digestive System & Abdominal Procedures 93,949$ 95,546$ 240 Digestive Malignancy 78,562$ 79,898$ 241 Peptic Ulcer & Gastritis 32,054$ 32,599$ 242 Major Esophageal Disorders 47,974$ 48,790$ 243 Other Esophageal Disorders 25,735$ 26,172$ 244 Diverticulitis & Diverticulosis 24,716$ 25,136$ 245 Inflammatory Bowel Disease 41,673$ 42,381$ 246 Gastrointestinal Vascular Insufficiency 35,537$ 36,141$ 247 Intestinal Obstruction 27,451$ 27,918$ 248 Major Gastrointestinal & Peritoneal Infections 47,875$ 48,689$ 249 Non-Bacterial Gastroenteritis, Nausea & Vomiting 19,937$ 20,276$ 251 Abdominal Pain 20,970$ 21,326$ 252 Malfunction, Reaction & Complication Of G.I. Device Or Procedure 46,786$ 47,581$ 253 Other & Unspecified Gastrointestinal Hemorrhage 43,178$ 43,912$ 254 Other Digestive System Diagnoses 30,427$ 30,944$ 260 Major Pancreas, Liver & Shunt Procedures 155,997$ 158,649$ 261 Major Biliary Tract Procedures 123,946$ 126,053$ 262 Cholecystectomy Except Laparoscopic 67,556$ 68,704$ 263 Laparoscopic Cholecystectomy 40,184$ 40,867$ 264 Other Hepatobiliary, Pancreas & Abdominal Procedures 138,160$ 140,509$ 279 Hepatic Coma & Other Major Acute Liver Disorders 72,230$ 73,458$ 280 Alcoholic Liver Disease 68,779$ 69,948$ 281 Malignancy of Hepatobiliary System & Pancreas 71,024$ 72,231$ 282 Disorders of Pancreas Except Malignancy 35,933$ 36,544$ 283 Other Disorders Of The Liver 51,508$ 52,384$ 284 Disorders of the Gallbladder & Biliary Tract 39,286$ 39,954$ 301 Hip Joint Replacement 65,799$ 66,918$ 302 Knee Joint Replacement 61,532$ 62,578$ 303 Dorsal & Lumbar Fusion Proc for Curvature of Back 210,600$ 214,180$ 304 Dorsal & Lumbar Fusion Proc Except for Curvature of Back 148,526$ 151,051$ 305 Amputation of Lower Limb Except Toes 159,903$ 162,621$ 308 Hip & Femur Procedures for Trauma Except Joint Replacement 72,819$ 74,057$ 309 Hip & Femur Procedures for Non-Trauma Except Joint Replacement 77,944$ 79,269$ 310 Intervertebral Disc Excision & Decompression 35,260$ 35,859$ 312 Skin Graft, Except Hand, For Musculoskeletal & Connective Tissue Diagnoses 190,600$ 193,840$ 313 Knee & Lower Leg Procedures Except Foot 54,541$ 55,468$ 314 Foot & Toe Procedures 68,279$ 69,440$ 315 Shoulder, Upper Arm & Forearm Procedures 47,153$ 47,955$ 316 Hand & Wrist Procedures 31,669$ 32,207$ 317 Tendon, Muscle & Other Soft Tissue Procedures 47,614$ 48,423$ 320 Other Musculoskeletel System & Connective Tissue Procedures 76,348$ 77,646$ 321 Cervical Spinal Fusion & Other Back/Neck Proc Exc Disc Excis/Decomp 66,129$ 67,253$ 340 Fractures of Femur 44,693$ 45,453$ 341 Fracture of Pelvis or Dislocation of Hip 36,852$ 37,478$ 342 Fracture or Dislocation Except Femur, Pelvis & Back 24,417$ 24,832$ 343 Musculoskeletal Malignancy & Pathol Fractures D/T Muscskel Malig 104,066$ 105,835$ 344 Osteomyelitis, Septic Arthritis & Other Musculoskeletal Infections 79,002$ 80,345$ 346 Connective Tissue Disorders 57,593$ 58,572$ 347 Other Back & Neck Disorders, Fractures & Injuries 30,329$ 30,845$ 349 Malfunction, Reaction & Comp of Orthopedic Device or Procedure 53,457$ 54,366$ 351 Other Musculoskeletal System & Connective Tissue Diagnoses 30,848$ 31,372$

58




Effective 1/1/10

361 Skin Graft for Skin & Subcutaneous Tissue Diagnoses 81,686$ 83,075$ 362 Mastectomy Procedures 62,823$ 63,891$ 363 Breast Procedures Except Mastectomy 42,171$ 42,888$ 364 Other Skin, Subcutaneous Tissue & Related Procedures 49,079$ 49,913$ 380 Skin Ulcers 49,330$ 50,169$ 381 Major Skin Disorders 45,976$ 46,758$ 382 Malignant Breast Disorders 61,360$ 62,403$ 383 Cellulitis & Other Bacterial Skin Infections 29,279$ 29,777$ 384 Contusion, Open Wound & Other Trauma To Skin & Subcutaneous Tissue 21,878$ 22,250$ 385 Other Skin, Subcutaneous Tissue & Breast Disorders 28,214$ 28,694$ 401 Pituitary & Adrenal Procedures 73,925$ 75,182$ 403 Procedures for Obesity 39,053$ 39,717$ 404 Thyroid, Parathyroid & Thyroglossal Procedures 25,521$ 25,955$ 405 Other Procedures for Endocrine, Nutrititional & Metabolic Disorders 163,409$ 166,187$ 420 Diabetes 29,772$ 30,278$ 421 Malnutrition, Failure To Thrive & Other Nutritional Disorders 56,254$ 57,210$ 422 Hypovolemia & Related Electrolyte Disorders 28,052$ 28,529$ 423 Inborn Errors of Metabolism 51,648$ 52,526$ 424 Other Endocrine Disorders 37,211$ 37,844$ 425 Electrolyte Disorders Except Hypovolemia Related 34,544$ 35,131$ 440 Kidney Transplant 313,242$ 318,567$ 441 Major Bladder Procedures 124,443$ 126,559$ 442 Kidney & Urinary Tract Procedures for Malignancy 59,855$ 60,873$ 443 Kidney & Urinary Tract Procedures for Nonmalignancy 61,205$ 62,245$ 444 Renal Dialysis Access Device Procedure Only 119,850$ 121,887$ 445 Other Bladder Procedures 51,919$ 52,802$ 446 Urethral & Transurethral Procedures 29,257$ 29,754$ 447 Other Kidney, Urinary Tract & Related Procedures 103,333$ 105,090$ 460 Renal Failure 62,686$ 63,752$ 461 Kidney & Urinary Tract Malignancy 70,653$ 71,854$ 462 Nephritis & Nephrosis 41,825$ 42,536$ 463 Kidney & Urinary Tract Infections 28,608$ 29,094$ 465 Urinary Stones & Acquired Upper Urinary Tract Obstruction 23,172$ 23,566$ 466 Malfunction, Reaction & Complic of Genitourinary Device Or Proc 62,665$ 63,730$ 468 Other Kidney & Urinary Tract Diagnoses, Signs & Symptoms 37,806$ 38,449$ 480 Major Male Pelvic Procedures 40,983$ 41,680$ 481 Penis Procedures 58,138$ 59,126$ 482 Transurethral Prostatectomy 26,302$ 26,749$ 483 Testes & Scrotal Procedures 29,318$ 29,816$ 484 Other Male Reproductive System & Related Procedures 69,585$ 70,768$ 500 Malignancy, Male Reproductive System 67,508$ 68,656$ 501 Male Reproductive System Diagnoses Except Malignancy 28,213$ 28,693$ 510 Pelvic Evisceration, Radical Hysterectectomy & Radical GYN Procs 57,674$ 58,654$ 511 Uterine & Adnexa Procedures for Ovarian & Adnexal Malignancy 76,630$ 77,933$ 512 Uterine & Adnexa Procedures for Non-ovarian & Non-adnexal Malig 41,521$ 42,227$ 513 Uterine & Adnexa Procedures for Non-Malignancy Except Leiomyoma 27,241$ 27,704$ 514 Female Reproductive System Reconstructive Procedures 25,454$ 25,887$ 517 Dilation & Curettage For Non-Obstetric Procedures 25,931$ 26,372$ 518 Other Female Reproductive System & Related Procedures 35,512$ 36,116$ 519 Uterine & Adnexa Procedures For Leiomyoma 30,112$ 30,624$ 530 Female Reproductive System Malignancy 71,738$ 72,958$ 531 Female Reproductive System Infections 25,936$ 26,377$ 532 Menstrual & Other Female Reproductive System Disorders 23,556$ 23,956$

59




Effective 1/1/10

540 Cesarean Delivery 26,613$ 27,065$ 541 Vaginal Delivery w/ Sterilization &/or D&C 23,722$ 24,125$ 542 Vaginal Delivery w/ Complicating Procedures Exc Sterilization &/or D&C 18,206$ 18,516$ 544 D&C, Aspiration Curettage or Hysterotomy For Obstetric Diagnoses 20,065$ 20,406$ 545 Ectopic Pregnancy Procedure 26,481$ 26,931$ 546 Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses 30,101$ 30,613$ 560 Vaginal Delivery 16,387$ 16,666$ 561 Postpartum & Post Abortion Diagnoses w/o Procedure 23,430$ 23,828$ 563 Threatened Abortion 18,955$ 19,277$ 564 Abortion w/o D&C, Aspiration Curettage or Hysterotomy 15,869$ 16,139$ 565 False Labor 8,099$ 8,237$ 566 Other Antepartum Diagnoses 21,557$ 21,923$ 580 Neonate, Transferred <5 Days Old, Not Born Here 37,407$ 38,043$ 581 Neonate, Transferred <5 Days Old, Born Here 7,269$ 7,393$ 583 Neonate, w/ ECMO 1,812,166$ 1,842,973$ 588 Neonate BWT <1500G W Major Procedure 1,365,643$ 1,388,859$ 589 Neonate BWT < 500G 17,645$ 17,945$ 591 Neonate, Birthwt 500-749G w/o Major Procedure 1,202,483$ 1,222,925$ 593 Neonate, Birthwt 750-999G w/o Major Procedure 643,591$ 654,532$ 602 Neonate, Birthwt 1000-1249G w/ Resp Dist Synd/Oth Maj Resp Or Maj Anom 467,269$ 475,213$ 603 Neonate, Birthwt 1000-1249G W OR W/O Other Significant Condition 380,905$ 387,380$ 607 Neonate, BWT 1250-1499G W Resp Dist Synd/Oth Maj Resp Or Maj Anom 350,137$ 356,089$ 608 Neonate, Birthwt 1250-1499G W OR W/O Other Significant Condition 204,074$ 207,543$ 609 Neonate, BWT 1500-2499G W Major Procedure 549,565$ 558,908$ 611 Neonate, Birthwt 1500-1999G W Major Anomaly 261,139$ 265,578$ 612 Neonate, BWT 1500-1999G W Resp Dist Synd/Oth Maj Resp Cond 228,389$ 232,272$ 613 Neonate, Birthwt 1500-1999G W Congenital/Perinatal Infection 176,654$ 179,657$ 614 Neonate, Birthwt 1500-1999G W OR W/O Other Significant Condition 123,799$ 125,904$ 621 Neonate, BWT 2000-2499G W Major Anomaly 154,340$ 156,964$ 622 Neonate, BWT 2000-2499G W Resp Dist Synd/Oth Maj Resp Cond 108,530$ 110,375$ 623 Neonate, Birthwt 2000-2499G W Congenital/Perinatal Infection 91,827$ 93,388$ 625 Neonate, Birthwt 2000-2499G W Other Significant Condition 102,563$ 104,307$ 626 Neonate, BWT 2000-2499G, Normal Newborn Or Neonate W Other Problem 37,043$ 37,673$ 630 Neonate, Birthwt > 2499g w/ Major Cardiovasc Procedure 417,996$ 425,102$ 631 Neonate, Birthwt > 2499g w/ Other Major Procedure 520,799$ 529,653$ 633 Neonate, Birthwt > 2499g w/ Major Anomaly 52,864$ 53,763$ 634 Neonate, Birthwt > 2499g W Resp Dist Synd/Oth Maj Resp Cond 76,755$ 78,060$ 636 Neonate, Birthwt > 2499g W Congenital/Perinatal Infection 51,248$ 52,119$ 639 Neonate, Birthwt > 2499g W Other Significant Condition 38,908$ 39,569$ 640 Neonate, Bwt > 2499g, Normal Newborn Or Neonate W Other Problem 6,835$ 6,951$ 650 Splenectomy 76,562$ 77,864$ 651 Other Procedures of Blood & Blood Forming Organs 64,011$ 65,099$ 660 Major Hematologic/Immunologic Diag Exc Sickle Cell Crisis & Coagul 65,791$ 66,909$ 661 Coagulation & Platelet Disorders 67,194$ 68,336$ 662 Sickle Cell Anemia Crisis 48,262$ 49,082$ 663 Other Anemia & Disorders Of Blood & Blood Forming Organs 33,178$ 33,742$ 680 Major O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 180,596$ 183,666$ 681 Other O.R. Procedures For Lymphatic/Hematopietic/Other Neoplasms 96,573$ 98,215$ 690 Acute Leukemia 449,551$ 457,193$ 691 Lymphoma & Non-acute Leukemia 130,970$ 133,196$ 692 Radiotherapy 55,851$ 56,800$ 693 Chemotherapy 52,347$ 53,237$ 694 Lymphatic & Other Malignancies & Neoplasms Of Uncertain Behavior 78,355$ 79,687$

60




Effective 1/1/10

710 Infectious & Parasitic Diseases Including HIV W O.R. Procedure 293,318$ 298,304$ 711 Post-Op,Post-Trauma, Other Device Infections W O.R. Procedure 115,396$ 117,358$ 720 Septicemia & Disseminated Infections 105,463$ 107,256$ 721 Post-Operative, Post-Traumatic, Other Device Infections 47,266$ 48,070$ 722 Fever 26,738$ 27,193$ 723 Viral Illness 23,249$ 23,644$ 724 Other Infectious & Parasitic Diseases 50,565$ 51,425$ 740 Mental Illness Diagnosis W O.R. Procedure 127,079$ 129,239$ 750 Schizophrenia 38,518$ 39,173$ 751 Major Depressive Disorders & Other/Unspecified Psychoses 52,044$ 52,929$ 752 Disorders of Personality & Impulse Control 7,567$ 7,696$ 753 Bipolar Disorders 21,720$ 22,089$ 754 Depression Except Major Depressive Disorder 12,561$ 12,775$ 755 Adjustment Disorders & Neuroses Except Depressive Diagnoses 14,262$ 14,504$ 756 Acute Anxiety & Delirium States 19,250$ 19,577$ 757 Organic Mental Health Disturbances 55,407$ 56,349$ 758 Childhood Behavioral Disorders 21,778$ 22,148$ 759 Eating Disorders 80,589$ 81,959$ 760 Other Mental Health Disorders 30,769$ 31,292$ 770 Drug & Alcohol Abuse or Dependence, Left Against Medical Advice 17,247$ 17,540$ 772 Alcohol & Drug Dependence w/ Rehab/Detox Therapy 33,014$ 33,575$ 773 Opioid Abuse & Dependence 30,541$ 31,060$ 774 Cocaine Abuse & Dependence 31,363$ 31,896$ 775 Alcohol Abuse & Dependence 28,419$ 28,902$ 776 Other Drug Abuse & Dependence 35,151$ 35,749$ 791 O.R. Procedure For Other Complications Of Treatment 71,659$ 72,877$ 811 Allergic Reactions 16,328$ 16,606$ 812 Poisoning Of Medicinal Agents 26,303$ 26,750$ 813 Other Complications of Treatment 34,142$ 34,722$ 815 Other Injury, Poisoning & Toxic Effect Diagnoses 28,341$ 28,823$ 816 Toxic Effects Of Non-Medicinal Substances 30,189$ 30,702$ 841 Extensive 3rd Degree Burns W Skin Graft 1,216,922$ 1,237,610$ 842 Full Thickness Burns W Skin Graft 232,033$ 235,978$ 843 Extensive 3rd Degree Or Full Thickness Burns W/O Skin Graft 96,967$ 98,615$ 844 Partial Thickness Burns W Or W/O Skin Graft 97,005$ 98,654$ 850 Procedure W Diag Of Rehab, Aftercare Or Oth Contact W Health Service 76,084$ 77,377$ 860 Rehabilitation 65,810$ 66,929$ 861 Signs, Symptoms & Other Factors Influencing Health Status 29,809$ 30,316$ 862 Other Aftercare & Convalescence 67,325$ 68,470$ 863 Neonatal Aftercare 123,793$ 125,897$ 890 HIV W Multiple Major HIV Related Conditions 213,372$ 216,999$ 892 HIV W Major HIV Related Condition 85,989$ 87,451$ 893 HIV W Multiple Significant HIV Related Conditions 73,871$ 75,127$ 894 HIV W One Signif HIV Cond Or W/O Signif Related Cond 43,109$ 43,842$ 910 Craniotomy For Multiple Significant Trauma 231,236$ 235,167$ 911 Extensive Abdominal/Thoraic Procedures For Mult Significant Trauma 290,996$ 295,943$ 912 Musculoskeletal & Other Procedures For Multiple Significant Trauma 285,639$ 290,495$ 930 Multiple Significant Trauma W/O O.R. Procedure 72,064$ 73,289$ 950 Extensive Procedure Unrelated To Principal Diagnosis 209,195$ 212,751$ 951 Moderately Extensive Procedure Unrelated To Principal Diagnosis 112,237$ 114,145$ 952 Nonextensive Procedure Unrelated To Principal Diagnosis 67,746$ 68,898$

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dqe department of health state of new york€¦ · • column 9: medical rehabilitation billing...

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