Minn. R. agency 196, ch. 9500, HOSPITAL MEDICAL ASSISTANCE REIMBURSEMENT, pt. 9500.1100 - DEFINITIONS

Subpart 1. Scope.

As used in parts 9500.1090 to 9500.1140, the terms in subparts 1a to 51 are defined as follows.

Subp. 1a. Accommodation service.

"Accommodation service" means those inpatient hospital services included by a hospital in a daily room charge. Accommodation services are composed of general routine services and special care units. These routine and special care units include the nursery, coronary, intensive, neonatal, rehabilitation, psychiatric, and chemical dependency care units.

Subp. 2. Adjusted base year operating cost.

"Adjusted base year operating cost" means a hospital's allowable base year operating cost per admission or per day, adjusted by the hospital cost index.

Subp. 3. Admission.

"Admission" means the time of birth at a hospital or the act that allows a patient to officially enter a hospital to receive inpatient hospital services under the supervision of a physician who is a member of the medical staff.

Subp. 4. [Repealed, 18 SR 1115]
Subp. 4a. [Repealed, 18 SR 1115]
Subp. 5. Allowable base year operating cost.

"Allowable base year operating cost" means a hospital's base year inpatient hospital cost per admission or per day, that is adjusted for case mix and excludes property costs.

Subp. 6. Ancillary service.

"Ancillary service" means inpatient hospital services that include laboratory and blood, radiology, anesthesiology, electrocardiology, electroencephalography, pharmacy and intravenous therapy, delivery and labor room, operating and recovery room, emergency room and outpatient clinic, observation beds, respiratory therapy, physical therapy, occupational therapy, speech therapy, medical supplies, renal dialysis, and psychiatric and chemical dependency services customarily charged in addition to an accommodation service charge.

Subp. 7. [Repealed, 18 SR 1115]
Subp. 8. [Repealed, 18 SR 1115]
Subp. 8a. [Repealed, 18 SR 1115]
Subp. 9. Base year.

"Base year" means a hospital's fiscal year that is recognized by Medicare, or a hospital's fiscal year specified by the commissioner if a hospital is not required to file information with Medicare, from which cost and statistical data are used to establish medical assistance and general assistance medical care rates.

Subp. 10. [Repealed, 18 SR 1115]
Subp. 11. Case mix.

"Case mix" means a hospital's admissions distribution of relative values among the diagnostic categories.

Subp. 12. [Repealed, 18 SR 1115]
Subp. 12a. Charges.

"Charges" means the usual and customary payment requested by the hospital of the general public.

Subp. 12b. City of the first class.

"City of the first class" means a city that has more than 100,000 inhabitants, provided that once a city is defined to be of the first class, it shall not be reclassified unless its population decreases by 25 percent from the census figures which last qualified the city for inclusion in the class.

Subp. 13. [Repealed, 18 SR 1115]
Subp. 14. Commissioner.

"Commissioner" means the commissioner of the Department of Human Services or an authorized representative of the commissioner.

Subp. 15. [Repealed, 18 SR 1115]
Subp. 16. Cost-to-charge ratio.

"Cost-to-charge ratio" means a ratio of a hospital's inpatient hospital costs to its charges.

Subp. 17. [Repealed, 18 SR 1115]
Subp. 18. Day outlier.

"Day outlier" means an admission whose length of stay exceeds the mean length of stay for neonate and burn diagnostic categories by one standard deviation, and in the case of all other diagnostic categories by two standard deviations.

Subp. 19. Department.

"Department" means the Minnesota Department of Human Services.

Subp. 20. [Repealed, 18 SR 1115]
Subp. 20a. Diagnostic categories.

"Diagnostic categories" means the diagnostic classifications containing one or more diagnosis related groups (DRG's) used by the Medicare program and identified in parts 9500.1090 to 9500.1140. The DRG classifications must be assigned according to the base year program and specialty groups with modifications as specified in subparts 20b to 20g.

Subp. 20b. Diagnostic categories eligible under the medical assistance program.

The following diagnostic categories are for persons eligible under the medical assistance program except as provided in subpart 20d, 20e, or 20f:

DIAGNOSTIC CATEGORIES DRG NUMBERS WITHIN DIAGNOSTIC CATEGORIES INTERNATIONAL CLASSIFICATION OF DISEASES, 9th Ed., CLINICAL MODIFICATIONS CODES
A. Nervous System Diseases and Disorders

(1) Intracranial vascular procedures with PDx of hemorrhage 528
(2) Crainiotomy for multiple significant trauma, Implant of chemotherapeutic agent or complex CNS diagnosis 484, 543
(3) Ventricular shunt, all ages, with CC and Crainiotomy, age > 17, with CC 001, 003, 529 003 includes shunt with CC as the principal procedure
(4) Spinal and Extracranial procedures, and Stroke with thrombolytic agent 531-533, 559
(5) Craniotomy, age 0-17 003 003 excludes shunt as the principal procedure
(6) Craniotomy, age > 17 without CC and Other nervous system procedures with CC 002, 007
(7) Other nervous system, Ventricular shunt and Extracranial procedures without CC 003, 008, 530, 534 003 includes shunt without CC as the principal procedure
(8) Spinal disorders and injury, Nervous system infection, and Hypertensive encephalopathy 009, 020, 022
(9) Intracranial hemorrhage or Cerebral infarction 014
(10) Neoplasms and Degenerative disorders of the nervous system, Stupor with coma > 1 hour 010, 012, 027
(11) Nonspecific cerebrovascular disorders and Stupor with coma < 1 hour with CC, and Other disorders of the nervous system 016, 028, 034, 035
(12) Nonspecific CVA, Cranial and peripheral nerve disorder, Other stupor and coma 015, 018, 023, 030
(13) Seizure and headache age > 17, with CC 024
(14) Nervous system neoplasm without CC, Multiple Sclerosis, and Cerebral Ataxia 011, 013
(15) Other nervous system diseases and disorders 017, 019, 021, 026, 029, 033, 524
(16) Seizure and headache without CC and Concussion, age > 17 025, 031, 032
B. Eye Diseases and Disorders

(1) Surgical procedures of Eyes 036-042
(2) Eye disorders and diseases 043-048
C. Ear, Nose, Throat, and Mouth Diseases and Disorders

(1) [Reserved for future use]
(2) [Reserved for future use]
(3) [Reserved for future use]
(4) [Reserved for future use]
(5) Other ENT and mouth OR procedures 063
(6) Miscellaneous and major ear, nose, throat and mouth procedures 049, 055 Codes in DRG 049 except 20.96-20.98
(7) Cochlear Implants only 049 Codes 20.96-20.97
(8) Sinus, mastoid, salivary gland and nose procedures 050, 053, 054, 056
(9) T&A, Myringotomy, and Salivary gland procedures 051, 057, 060, 061, 062
(10) Cleft lip and palate repair and Other T & A procedures 052, 058, 059
(11) Epiglottis, Nasal trauma, and ENT and mouth malignancy 064, 067, 072, 073
(12) Other ENT and mouth diagnoses and other mouth procedures 066, 068, 074, 168, 169, 185, 187
(13) Disequilibrium, Otitis media with CC, age 0-17, and Other dental and throat disease 065, 069, 070, 071, 186
D. Respiratory System Diseases and Disorders

(1) With Ventilator support < 96 hrs 475 excludes 96.72
(2) With ventilator support 96+ hrs 475 includes 96.72
(3) [Reserved for future use]
(4) [Reserved for future use]
(5) [Reserved for future use]
(6) Respiratory neoplasms 082
(7) [Reserved for future use]
(8) [Reserved for future use]
(9) COPD, Simple pneumonia with CC, Chest trauma without CC, and Other respiratory disorders 084, 088, 089
(10) Tracheostomy for face, mouth, and neck diagnoses 482
(11) Bronchitis and asthma with CC or Simple pneumonia and pleurisy except with CC 090, 091, 096
(12) Pleural effusion, Infection and inflammation with CC, Pulmonary edema and respiratory failure 079, 085, 087
(13) Pulmonary embolism and Other respiratory diseases with CC 078, 101
(14) [Reserved for future use]
(15) Specific respiratory system diseases and disorders 080, 081, 083, 092
(16) Pleural effusion, Pneumothorax, Bronchitis and Other diagnoses without CC 086, 095, 097, 098, 100, 102
(17) Ventilator 96+ hours With ECMO/Tracheostomy with major surgery or With extensive burns with skin graft 504, 541
(18) Tracheostomy with ventilator 96+ hours or without major surgery 542
(19) Major chest procedures 075
(20) Other respiratory system OR procedures with CC 076
(21) Other respiratory system OR procedures without CC 077
E. Circulatory System Diseases and Disorders

(1) Major cardiac surgeries 105, 106, 108, 110, 547, 549
(2) [Reserved for future use]
(3) Permanent cardiac pacemaker except device replacement without major CV disease, and other procedures for circulatory disease 114, 517, 552
(4) Major cardiac surgery and implantable defibrillator 104, 515, 535, 536
(5) Other cardiac interventional and vascular procedures, and Pacemaker device replacement 118, 120, 479, 518, 554, 556
(6) Amputation for circulatory disease except upper limb and toe 113
(7) Drug-eluding stent, Other vascular procedures, Cardiac pacemaker with major CV diagnosis or AICD lead or generator 551, 553, 557, 558
(8) Heart failure and shock and Unexplained cardiac arrest 127, 129
(9) AMI without major complications, Cardiac cath without complex diagnoses, and Hypertension 122, 125, 134
(10) Peripheral vascular disease with CC 130
(11) Acute MI and Other circulatory diagnoses with CC and endocarditis 121, 126, 144
(12) ASHD with CC, Other circulatory conditions without CC, and Vein ligation and stripping 119, 132, 139, 140, 143, 145
(13) Deep vein thrombophlebitis, peripheral vascular disorders without CC, Congenital valve disease, age > 17 and Arrhythmia with CC 128, 131, 135, 136, 138
(14) Major CV procedure without CC, Acute MI, expired, and Cardiac cath with complex diagnosis 111, 123, 124
(15) Syncope and collapse with and without CC 141, 142
(16) Atherosclerosis with CC, Congenital and valvular disorders, age 0-17 133, 137
(17) Coronary bypass with and without cath, without major CV diagnosis 548, 550
(18) Percutaneous cardiovascular procedure with major CV diagnosis 555
F. Digestive System Diseases and Disorders

(1) Anal/stomal, Hernia, Appendectomy and other procedures 158, 162, 163, 167
(2) Hernia procedures age > 17, Appendectomy without complicating diagnosis with CC 160, 161, 166
(3) Bowel and other digestive system surgery 147, 151, 153, 155, 157, 159, 165, 171
(4) Stomach and esophagus procedures and Digestive disease, age 0-17 149, 156, 164, 172, 190
(5) Other surgical procedures of the digestive system with CC 152, 170
(6) Rectal resection, Lysis of peritoneal adhesions and Other major bowel surgery 146, 148, 150, 154
(7) Digestive system conditions including malignancy, hemorrhage and obstruction 173, 174, 180, 188
(8) Other bowel, stomach, digestive system diseases with and without CC 176, 177, 179, 182, 189
(9) Digestive system Obstruction, Uncomplicated ulcer, and GI hemorrhage 175, 178, 181, 183, 184
G. Hepatobiliary System Diseases and Disorders

(1) Liver and Biliary tract disorders without CC 206, 208
(2) Disorders of the pancreas except malignancy 204
(3) Other disorders of liver except malignancy, cirrhosis, and alcoholic hepatitis with CC 205
(4) Malignancy of hepatobiliary system or pancreas and Cirrhosis and alcoholic hepatitis 202, 203
(5) Biliary tract disorders, laparoscopic chole without CDC, without CC 194, 207, 494
(6) Cholecystectomy except lap without CC and laparoscopic chole with CC 196, 198, 493
(7) Other surgery for liver, gall bladder and pancreas disease 192, 195, 197, 199, 200
(8) Biliary, Pancreas and Liver procedures with CC 191, 193, 201
H. Diseases and Disorders of the Musculoskeletal System and Connective Tissues

(1) Combined anterior/posterior spinal fusion 496, 546
(2) Spinal fusion except cervical without CC 497
(3) Hip and femur procedures with CC and other musculoskeletal surgery 210, 217, 233, 471, 498, 501
(4) Surgeries of hip and lower extremity and cervical fusion without CC 212, 213, 216, 519, 544, 545
(5) Back and neck except fusion and Lower extremity procedures 211, 218, 220, 228, 234, 491, 499
(6) Other surgeries for soft tissue and removal of fix device 226, 227, 520, 537
(7) Other orthopedic procedures on lower extremity 219, 225, 230, 502, 503
(8) Upper extremity and back procedures without CC 223, 500, 538
(9) Carpal tunnel release and Minor arm procedures 006, 224, 229, 232
(10) Connective tissue disorders 240, 242, 244
(11) Pathological fracture, musculoskeletal malignancy and Septic arthritis 239, 242
(12) Fractures, sprains and other injuries 235-238, 241, 243, 245, 248, 250, 253, 255, 256
(13) Other musculoskeletal disorders, Signs and Symptoms, Limb injury, and Aftercare 246, 247, 249, 251, 252, 254
I. Diseases and Disorders of the Skin, Subcutaneous Tissue, and Breast

(1) Skin graft and debridement with CC and Malignant breast disease 263, 265, 274
(2) Treated with skin graft, biopsy, or debridement 262, 264, 266, 269, 271
(3) Other skin and subcutaneous diseases and procedures 257, 258, 261, 267, 270, 272, 273, 275, 277
(4) Subtotal mastectomy and Other skin, subcutaneous tissue, and breast conditions 259, 260, 268, 278-280, 282, 283
(5) Nonmalignant breast and Minor skin disorders without CC 276, 281, 284
J. Endocrine, Nutritional, and Metabolic Diseases and Disorders

(1) Major surgical procedures 285-288, 292, 293
(2) Diabetes, age > 35 294
(3) Nutritional and miscellaneous metabolic conditions, age > 17 and inborn metabolic errors 296, 299
(4) Metabolic disorders, age 0-17 and Diabetes, age 0-35 295, 298
(5) Metabolic disorders, age > 17 and Endocrine disorders without CC 297, 301
(6) Other endocrine, nutritional, and metabolic conditions 289-291, 300
K. Kidney and Urinary Tract Diseases and Disorders

(1) Kidney, ureter, or major bladder procedures 303, 304, 315
(2) Prostatectomy and kidney procedures for non-neoplasm 305, 306, 308, 312
(3) Neoplasms with CC and other kidney and urinary tract conditions without CC or age 0-17 318, 331, 333
(4) Renal failure 316
(5) Other kidney and urinary tract conditions and Admission for renal dialysis 317, 320-322, 325, 328, 332
(6) Kidney stones and other kidney and urinary symptoms without CC 319, 324, 326, 327, 329, 330
(7) TURP and other prostate surgeries 307, 309-311, 313, 314, 323
L. Male Reproductive System Diseases and Disorders

(1) Treated with major surgery or with CC 334, 336, 338, 340, 341, 344
(2) Treated with minor surgery or without CC 335, 337, 339, 342, 343, 345
(3) Malignancy and other diseases treated without surgery 346, 347, 348, 349, 350, 351, 352
M. Female Reproductive System Diseases and Disorders

(1) Tubal interruption and Reconstructive procedures, D&C, conization except for malignancy 356, 361, 362, 364
(2) Uterine and adnexa procedures without CC 355, 359, 363, 367
(3) Menstrual and Other female reproductive system infections and disorders 368, 369
(4) [Reserved for future use]
(5) Other female reproductive system procedures 358, 360, 365
(6) Pelvic evisceration, radical hysterectomy, surgery and medical treatment for malignancy 353, 354, 357, 366
N. Pregnancy Related Conditions

(1) Postpartum and postabortion diagnoses with surgery 377
(2) Ectopic pregnancy and other antepartum diagnoses without CC 378, 384
(3) Postpartum and postabortion conditions treated without surgery 376
(4) Abortion with surgery 381
(5) [Reserved for future use]
(6) Threatened abortion 379
(7) Abortion without D&C, False labor, and Other conditions without surgery 380, 382, 383
O. [Reserved for future use]
P. Blood and Immunity Disorders

(1) Splenectomy and Other surgical procedures of blood forming organs 392, 393, 394
(2) [Reserved for future use]
(3) Red blood cell disorders age > 17 395
(4) Red blood cell disorders age 0-17 396
(5) Coagulation, reticuloendothelial and immunity disorders with CC 397, 398
(6) Reticuloendothelial and immunity disorders without CC 399
Q. Myeloproliferative Diseases and Disorders, Poorly Differentiated Malignancy and other Neoplasms

(1) [Reserved for future use]
(2) Treated with chemotherpay with acute leukemia as secondary diagnosis 492
(3) [Reserved for future use]
(4) Treated with radiotherapy or chemotherapy without acute leukemia 409, 410
(5) [Reserved for future use]
(6) Surgical treatments for myeloproliferative diseases and disorders 401, 402, 406-408, 539, 540
(7) Other nonsurgical treatments for myeloproliferative diseases and disorders 403-405, 411-414, 473
R. Infections and Parasitic Diseases

(1) Treated with surgical procedure 415
(2) Other infection and parasitic diseases 423
(3) Septicemia age > 17 416
(4) Septicemia age 0-17 417
(5) Postop and post-traumatic infections and Fever of unknown origin (FUO), age > 17 with CC 418, 419
(6) Viral illness and fever of unknown origin, age 0-17 422
(7) FUO without CC and Viral illness, age > 17 420, 421
S. Mental Diseases and Disorders

(1) Treated with surgical procedure (ages 0+) 424
(2) (Ages 0-17) 425, 427-429, 432
(3) (Ages > 17) 425, 427-429, 432
T. Substance Use and Substance Induced Organic Mental Disorder

(1) Ages 0-20, with CC 521 DRG 521 excludes procedures 94.61, 94.63, 94.64, 94.66, 94.67, 94.69
(2) Ages > 20, with CC 521 DRG 521 excludes procedures 94.61, 94.63, 94.64, 94.66, 94.67, 94.69
(3) Age 0-20, without CC and Rehab 523
(4) Age > 20, without CC and Rehab 523
U. [Reserved for future use]
V. Injuries, Poisonings, and Toxic Effects of Drugs

(1) Treated with surgical procedure 439, 440, 442
(2) Other surgery without CC and Hand procedures for injuries 441, 443
(3) [Reserved for future use]
(4) Traumatic injury age 0-17, Allergic reactions, and other poisoning without CC 446, 447, 448, 451, 453, 455
(5) Other toxic effects and Complications of treatment with CC 449, 452, 454
(6) Traumatic injury age > 17 and Toxic effects age > 17 without CC 444, 445, 450
W. Burns

(1) [Reserved for future use]
(2) [Reserved for future use]
(3) Extensive or full thickness with ventilation 96+ hours without skin graft or Extensive with other inhalation injury or significant trauma 505, 507, 508
(4) Nonextensive burns with or without CC or significant trauma 509, 510, 511
X. Factors Influencing Health Status

(1) OR procedures with diagnosis of other contact with health services 461
(2) Rehabilitation, Aftercare, and Signs and symptoms 462-467
Y. [Reserved for future use]
Z. [Reserved for future use]
AA. [Reserved for future use]
BB. [Reserved for future use]
CC. Caesarean Sections

(1) With complicating diagnosis 370
(2) Without complicating diagnosis 371
DD. Vaginal Delivery

(1) With complicating diagnosis 372
(2) Without complicating diagnosis or operating room procedures 373
(3) With operating room procedure 374, 375
(4) [Reserved for future use]
EE. [Reserved for future use]
FF. Depressive Neuroses

Depressive Neuroses 426
GG. Psychoses

(1) (Ages 0-17) 430
(2) (Ages > 17) 430
HH. Childhood Mental Disorders

Childhood Mental Disorders 431
II. Unrelated Operating Room Procedures

(1) Extensive 468
(2) Nonextensive 476, 477
JJ. [Reserved for future use]
KK. Extreme Immaturity

(1) Weight < 750 Grams 386 76501, 76502
(2) [Reserved for future use]
(3) [Reserved for future use]
(4) Weight 750 to 1499 Grams 386 387 76503-76505 76500
(5) Neonate respiratory distress syndrome 386 Codes in DRG 386 except 76501-76505
LL. Prematurity with Major Problems

(1) Weight < 1250 Grams 387 76511-76514
(2) Weight 1250 to 1749 Grams 387 76506-76510, 76515, 76516
(3) Weight > 1749 Grams 387 Codes in DRG 387 except 76500, 76506, 76510-76516
MM. Prematurity Without Major Problems and Neonates Died

Prematurity Without Major Problems and Neonates Died 385, 388 Includes neonates who expire in the birth hospital, and the discharge date is the same as the birth date
NN. Full Term Neonates With

(1) Major problems (Age 0) 389
(2) Other problems 390
OO. Multiple Significant Trauma

(1) Limb reattachment and Hip and Femur OR procedures 485
(2) Other multiple significant trauma without OR 487
(3) Full thick burn with skin graft or inhalation injury with CC or significant trauma and Other surgery for multiple significant trauma 486, 506
PP. [Reserved for future use]
QQ. Normal Newborns

Normal Newborns 391
RR. [Reserved for future use]
SS. [Reserved for future use]
TT. [Reserved for future use]
UU. Organ and Cell Transplants

(1) Heart transplants 103
(2) Liver and/or intestinal, Bone marrow, Lung, Simultaneous pancreas and kidney, Pancreas transplants and Other heart assist system implant 480, 481, 495, 512, 513, 525
(3) Kidney transplant 302
VV. [Reserved for future use]
WW. Human Immunodeficiency Virus

(1) Treated with extensive operating room procedure 488
(2) With major related condition 489
(3) With or without other related condition 490
Subp. 20c. [Repealed, 31 SR 819]
Subp. 20d. Diagnostic categories for persons eligible under the general assistance medical care program.

The following diagnostic categories are for persons eligible under the general assistance medical care program except as provided in subpart 20e or 20f:

DIAGNOSTIC CATEGORIES DRG NUMBERS WITHIN DIAGNOSTIC CATEGORIES INTERNATIONAL CLASSIFICATION OF DISEASES, 9th Ed., CLINICAL MODIFICATIONS CODES
A. Nervous System Conditions

(1) Intracranial vascular procedures with principal diagnosis of hemorrhage 528
(2) Craniotomy except craniotomy without CC 001, 003, 484, 531, 543
(3) Ventricular shunt and extracranial procedures with CC and acute stroke with thrombolytic agent 529, 533, 559
(4) Other neurological OR procedures or intracranial hemorrhage, cerebral infarct, and nervous system neoplasms 002, 007, 008, 014, 020, 530, 532, 534
(5) Spinal disorders and injuries, encephalopathy, cerebrovascular disorder, stupor and coma with CC 009, 016, 022, 028
(6) Nervous system neoplasms with CC, degenerative disorders, precerebral occlusion and other specified disorders 010, 012, 015, 021, 027, 034
(7) Seizure and headache except with CC or specified stupor and coma 017, 023, 024, 026, 029, 030
(8) Concussion and other nervous system diseases and disorders with and without CC 011, 013, 018, 019, 025, 031-033, 035, 524
B. Eye Diseases and Disorders

Eye Diseases and Disorders 036-048
C. Ear, Nose, Throat, and Mouth Diseases and Disorders

(1) Major head and ENT procedures 049, 050, 053, 054, 056, 059, 063
(2) Tonsillectomy, adenoidectomy, and Other ear, nose, throat, and mouth procedures 051, 052, 055, 057, 058, 060-062, 064, 185-187
(3) Epiglottis, Laryngotracheitis, and Other ENT conditions 067, 069, 071-073
(4) Disequilibrium, Epitaxis, Otitis media and URI except without CC 065, 066, 068, 070, 074
D. Respiratory System Conditions

(1) Treated with ventilator support for < 96 hrs 475 excludes procedure 96.72
(2) Treated with ventilator support for 96+ hours 475 includes procedure 96.72
(3) [Reserved for future use]
(4) P.E., Respiratory infections, Neoplasms, Pleural effusion, Pulmonary edema, and respiratory failure, and other conditions with CC 078-083, 085, 087, 092, 094, 101
(5) COPD, Pneumonia, Pneumothorax, Bronchitis and Other respiratory system conditions without CC 086, 088-091, 093, 095-099, 102
(6) Major chest trauma and Respiratory signs and symptoms without CC 084, 100
(7) Tracheostomy for face, mouth, and neck diagnoses and Full thickness burns 482, 508
(8) Major chest and other surgical procedure 075-077
E. Circulatory System Conditions

(1) [Reserved for future use]
(2) [Reserved for future use]
(3) [Reserved for future use]
(4) Valve replacement with cath, CABG with PTCA, and AICD implant with AMI, heart failure and shock 104, 106, 535, 536
(5) Major cardiothoracic and vascular procedures 105, 108, 110, 113, 515, 547, 553
(6) Other cardiac and circulatory surgeries and percutaneous procedures including drug-eluding stents 111, 120, 548, 549-552, 554, 555, 557, 558
(7) Procedures for circulatory disorders, Cardiac pacemaker revision or replacement, Acute MI with CC, and Endocarditis 114, 117, 118, 121, 123, 124, 126, 518, 556
(8) Heart failure and shock, other circulatory disorders with CC and vascular procedures without CC 127, 129, 130, 144, 479
(9) Vein ligation and stripping, Circulatory disorders with cath without CC 119, 125
(10) Uncomplicated AMI and Other circulatory system diagnoses without CC 122, 145
(11) Cardiac arrhythmias, Valve disorders, and Hypertension 131, 134-138
(12) Thrombophlebitis, Atherosclerosis, Angina, and Syncope 128, 132, 133, 139-142
(13) Chest pain 143
F. Digestive System Diseases and Disorders

(1) Major bowel, stomach, esophagus, and duodenal surgery with CC 146, 148, 154
(2) Minor bowel and Other digestive system surgeries with CC 150, 152, 156, 170
(3) Major bowel procedures without CC and Other digestive system procedures with CC 147, 149, 157, 164, 188
(4) Appendectomy without complicating principal diagnoses, Stomal and Hernia procedures 158, 160-163, 166-169
(5) Treated with other surgical procedure 151, 153, 155, 159, 165, 171
(6) GI hemorrhage and CC and Other digestive system diagnoses, age 0-17 174, 190
(7) Uncomplicated peptic ulcer and Other digestive system diseases 172, 177-180, 189
(8) Miscellaneous digestive disorders with CC and Digestive malignancy without CC 173, 182
(9) GI Hemorrhage and Obstruction without CC and Miscellaneous disorders except CC 175, 176, 181, 183, 184
G. Hepatobiliary System Conditions

(1) Pancreas, Liver, Shunt, and Hepatobiliary procedures 191, 193, 199, 201
(2) Cholecystectomy except laparoscopic and Diagnostic hepatobiliary procedures 194, 195, 197, 198, 200
(3) Cirrhosis and alcoholic hepatitis and Other liver disorders with CC 202, 205
(4) Pancreas, liver, shunt procedures without CC and biliary procedures with CC 192, 196, 493
(5) Lap cholecystectomy without CC 494
(6) Other disorders of liver and Pancreas and Hepatobiliary malignancy 203, 204, 206
(7) Disorders of biliary tract 207, 208
H. Diseases and Disorders of the Musculoskeletal System and Connective Tissues

(1) Major and high resource utilization surgery: Kidney transplant, Limb reattachment and Hip and femur surgery for trauma, Spinal fusion for curvature or malignancy 302, 485, 546
(2) Surgery on Hip and Femur, Multiple Joints, and Knee and Spinal Fusion 210, 471, 496, 497, 501
(3) Muscular system and connective tissue surgery and Wound debridement 217, 233
(4) Musculoskeletal disorder with Major OR procedure or OR without CC on lower extremity, hip, and spine 212, 226, 498, 519, 537, 545
(5) Lower extremity Amputation, Joint replacement, and Reattachment and Biopsy of Musculoskeletal tissue 213, 216, 218, 285, 544
(6) Other surgery on Hip, Lower extremity and Spine 225, 230, 491, 502, 520
(7) Minor lower extremity joint without CC and Major upper extremity joint procedure with CC 211, 219, 223, 228, 234
(8) Upper extremity procedures, Knee procedures without PDx of infection, and Removal of fixation device 220, 224, 503, 538
(9) Back and neck procedures except fusion, Arthroscopy, and Connective tissue disorders 232, 240, 241, 499, 500
(10) Pathological fracture and Musculoskeletal and Connective tissue malignancy 238, 239, 256
(11) Soft tissue procedures, Fractures, Injuries, Sprains and strains 227, 235, 236, 244, 250, 255
(12) Medical back problems and Other diseases and disorders 237, 242, 243, 245-248
(13) Aftercare, musculoskeletal system and connective tissue 249, 252, 253
(14) Injury to extremities without CC 251, 254
(15) [Reserved for future use]
(16) [Reserved for future use]
(17) [Reserved for future use]
(18) [Reserved for future use]
(19) Hand and wrist procedures and carpal tunnel release 006, 229, 441
I. Diseases and Disorders of the Skin, Subcutaneous Tissue, and Breast

(1) Treated with skin graft and/or debridement 263, 265, 287
(2) Malignant breast disorders with CC 266, 268, 270, 274
(3) Other skin, subcutaneous tissue and breast procedure with CC 264, 269
(4) Breast biopsy and mastectomy 257-260, 262, 277
(5) Other skin, subcutaneous tissue, and breast conditions 261, 267, 272, 276, 281, 283
(6) Skin ulcers and cellulitis 271, 279, 280, 282
(7) Malignant breast disorders without complication 273, 275, 278, 284
J. Endocrine, Nutritional, and Metabolic Diseases and Disorders

(1) Major surgical procedures 286, 288, 290-293
(2) Diabetes age > 35 and Inborn errors of metabolism 294, 299
(3) Diabetes age 0-35 295
(4) Endocrine, Nutritional and metabolic disorders 289, 296
(5) Endocrine disorders with CC 300
(6) Other endocrine, nutritional, and metabolic conditions except with CC 297, 298, 301
K. Kidney and Urinary Tract Conditions

(1) Kidney, ureter, and major bladder procedures 303, 304, 308, 315
(2) [Reserved for future use]
(3) KUB procedures without CC and Prostatectomy with CC 305, 306
(4) Other kidney and urinary tract procedures without CC and diagnosis with CC 307, 309, 310, 317, 319, 320, 331
(5) Kidney and urinary tract infection except with CC and Urethral procedures 311-314, 321-323
(6) Renal Failure, Neoplasms and Urethral stricture with CC 316, 318, 328, 333
(7) Other kidney and urinary tract conditions 324-327, 329, 330, 332
L. Male Reproductive System Conditions

(1) Major surgery 334, 335, 338-340, 344, 345
(2) Other medical and surgical treatments 336, 337, 341-343, 346-352
M. Female Reproductive System Diseases and Disorders

(1) Tubal interruption, D&C, Malignancy without CC, and Infection 362, 364, 367, 368
(2) [Reserved for future use]
(3) [Reserved for future use]
(4) Malignancy with CC, Other disorders and Reconstructive procedures 356, 359, 366, 369
(5) Pelvic evisceration, and Surgery for ovarian malignancy 353, 357
(6) Uterine, Adnexa, and Other OR procedures 354, 355, 358, 360, 361, 363, 365
N. Pregnancy Related Conditions

(1) Cesarean section and Postpartum complications with surgery 370, 371, 377
(2) Vaginal delivery and Other pregnancy related conditions and procedures 372-376, 378-384
O. [Reserved for future use]
P. Blood and Immunity Disorders

(1) Surgical procedure of the blood and blood forming organs and Coagulation disorders 392-394, 397
(2) RBC and Reticuloendothelial and Immunity disorders 395, 396, 398, 399
Q. Myeloproliferative Diseases and Disorders, Poorly Differentiated Malignancy and Other Neoplasms

(1) [Reserved for future use]
(2) [Reserved for future use]
(3) Surgical and other treatment for myeloproliferative diseases and disorders 401-403, 405, 406, 408, 473, 492, 539, 540
(4) Lymphoma, Leukemia, Radiotherapy and Chemotherapy 404, 407, 409-414
R. Infections and Parasitic Diseases

(1) Treated with surgical procedure 415
(2) Septicemia and Other infections and parasitic diseases 416, 417, 423
(3) Postop and post-traumatic infections 418
(4) Viral illness and Fever of unknown origin 419-422
S. Mental Diseases and Disorders

(1) Principal diagnosis of mental illness with surgery 424
(2) Adjustment reaction and Other Mental Disorders 425, 432
(3) Depressive neuroses and childhood mental disorders 426, 431
(4) Other psychiatric diseases and disorders 427, 428, 429
(5) Psychoses 430
T. Substance Use and Substance Induced Organic Mental Disorder

(1) With CC 521 DRG 521 excludes procedures 94.61, 94.63, 94.64, 94.66, 94.67, 94.69
(2) Without rehab, without CC 523
U. [Reserved for future use]
V. Injuries, Poisonings, and Toxic Effects of Drugs

(1) Treated with Skin grafts and Other surgical procedures for injuries with CC 439, 442
(2) Wound debridement and Other surgery for injuries without CC 440, 443
(3) Traumatic injury 444-446
(4) Allergic reactions 447, 448, 453
(5) Poisoning and toxic effects of drugs age > 17 with CC 449
(6) Poisoning and toxic effects of drugs age > 17 without CC and age 0-17 450, 451
(7) [Reserved for future use]
(8) Other injuries and toxic effects and Complications of treatment with CC 452, 454, 455
W. Burns

(1) Third degree burn without skin graft, without complication and Nonextensive burns 509-511
(2) [Reserved for future use]
(3) Full thickness with skin graft and extensive third degree burns 505, 507
X. Factors Influencing Health Status

(1) OR procedures with diagnosis of other contact with health services 461
(2) Rehabilitation, Aftercare, and Signs and symptoms 462-467
Y. [Reserved for future use]
AA. [Reserved for future use]
BB. [Reserved for future use]
CC. [Reserved for future use]
DD. [Reserved for future use]
EE. [Reserved for future use]
FF. [Reserved for future use]
GG. [Reserved for future use]
HH. [Reserved for future use]
II. Operating Room Procedure Unrelated to Principal Diagnosis

(1) Extensive 468
(2) Nonextensive 476, 477
JJ. [Reserved for future use]
KK. [Reserved for future use]
LL. [Reserved for future use]
MM. [Reserved for future use]
NN. [Reserved for future use]
OO. Multiple Significant Trauma

(1) Third degree burn with graft or inhalation injury with CC and Other surgery for multiple significant trauma 486, 506
(2) Multiple significant trauma without surgery 487
PP. [Reserved for future use]
QQ. [Reserved for future use]
RR. [Reserved for future use]
SS. [Reserved for future use]
TT. [Reserved for future use]
UU. ECMO/Tracheostomy and Burns

ECMO/Tracheostomy and Burns with ventilator 96+ hours, Organ and Cell transplants, and Heart assist system implant 103, 480, 481, 495, 504, 512, 513, 525, 541, 542
VV. [Reserved for future use]
WW. Human Immunodeficiency Virus

Human Immunodeficiency Virus 488-490
Subp. 20e. Diagnostic categories relating to a rehabilitation hospital or a rehabilitation distinct part.

The following diagnostic categories are for services provided within a rehabilitation hospital or a rehabilitation distinct part regardless of program eligibility:

DIAGNOSTIC CATEGORIES DRG NUMBERS WITHIN DIAGNOSTIC CATEGORIES INTERNATIONAL CLASSIFICATION OF DISEASES, 9th Ed., CLINICAL MODIFICATIONS CODES
A. Nervous System Diseases and Disorders

Nervous System Diseases and Disorders 001-003, 006-035, 524, 528-534, 543, 559 except codes in category Y and Z
B. [Reserved for future use]
C. [Reserved for future use]
D. [Reserved for future use]
E. [Reserved for future use]
F. [Reserved for future use]
G. [Reserved for future use]
H. Diseases and Disorders of the Musculoskeletal System and Connective Tissues

Diseases and Disorders of the Musculoskeletal System and Connective Tissues 210-213, 216-220, 223-230, 232-256, 471, 491, 496-503, 519, 520, 537, 538, 544-546 except codes in category Y and Z
I. [Reserved for future use]
J. [Reserved for future use]
K. [Reserved for future use]
L. [Reserved for future use]
M. [Reserved for future use]
N. [Reserved for future use]
O. [Reserved for future use]
P. [Reserved for future use]
Q. [Reserved for future use]
R. Mental Diseases and Disorders/Substance Use and Substance Induced Organic Mental Disorders

Mental Diseases and Disorders/Substance Use and Substance Induced Organic Mental Disorders 424-432, 521, 523 except codes in category Y and Z; DRG 521 excludes procedures 94.61, 94.63, 94.64, 94.66, 94.67, 94.69
S. Multiple Significant Trauma/Unrelated Operating Room Procedures

Multiple Significant Trauma/Unrelated Operating Room Procedures 468, 476, 477, 484-487 except codes in category Y and Z
T. Other Conditions Requiring Rehabilitation Services

Other Conditions Requiring Rehabilitation Services 036-106, 108, 110, 111, 113, 114, 117-208, 257-399, 401-423, 439-455, 461-467, 473, 475, 479-482, 488-490, 492-495, 504-518, 525, 535, 536, 539, 540-542, 547-558 except codes in category Y and Z
U. [Reserved for future use]
V. [Reserved for future use]
W. [Reserved for future use]
X. [Reserved for future use]
Y. Specific late effects or conditions secondary to a spinal cord or intracranial injury or skull fracture which result in paraplegia

Specific late effects or conditions secondary to a spinal cord or intracranial injury or skull fracture which result in paraplegia All DRGs Diagnosis codes 344.1, 806.21, 806.26, 806.31, 806.36, 952.11, 952.16 in combination with 905.0, 907.0, or 907.2, excluding cases with 781.0, 781.2, 781.3, and 781.4
Z. Specific late effects or conditions secondary to a spinal cord or intracranial injury or skull fracture which result in quadriplegia or hemiplegia

Specific late effects or conditions secondary to a spinal cord or intracranial injury or skull fracture which result in a quadriplegia or hemiplegia All DRGs Diagnosis codes 344.01-344.04, 344.09, 806.0x, 806.1x, or 952.0x in combination with 907.2, excluding cases with 781.0, 781.2, and 780.03; or Diagnosis codes 344.00-344.04,

344.09, 342.01, 342.81, or 342.91 in combination with 907.0 or 905.0, excluding cases 781.0, 781.3, and 780.03
Subp. 20f. Diagnostic categories for neonatal transfers.

The following diagnostic categories are for services provided to neonatal transfers at receiving hospitals with neonatal intensive care units regardless of program eligibility:

DIAGNOSTIC CATEGORIES DRG NUMBERS WITHIN DIAGNOSTIC CATEGORIES INTERNATIONAL CLASSIFICATION OF DISEASES, 9th Ed., CLINICAL MODIFICATIONS CODES
A. [Reserved for future use]
B. [Reserved for future use]
C. [Reserved for future use]
D. [Reserved for future use]
E. [Reserved for future use]
F. [Reserved for future use]
G. [Reserved for future use]
H. [Reserved for future use]
I. [Reserved for future use]
J. [Reserved for future use]
K. [Reserved for future use]
L. [Reserved for future use]
M. [Reserved for future use]
N. [Reserved for future use]
O. [Reserved for future use]
P. [Reserved for future use]
Q. [Reserved for future use]
R. [Reserved for future use]
S. [Reserved for future use]
T. [Reserved for future use]
U. [Reserved for future use]
V. [Reserved for future use]
W. [Reserved for future use]
X. [Reserved for future use]
Y. [Reserved for future use]
Z. [Reserved for future use]
AA. [Reserved for future use]
BB. [Reserved for future use]
CC. [Reserved for future use]
DD. [Reserved for future use]
EE. [Reserved for future use]
FF. [Reserved for future use]
GG. [Reserved for future use]
HH. [Reserved for future use]
II. [Reserved for future use]
JJ. [Reserved for future use]
KK. Extreme Immaturity and Tracheostomy

(1) [Reserved for future use]
(2) Weight < 750 Grams and Tracheostomy 386, 482 541, 542 76501, 76502
(3) [Reserved for future use]
(4) Weight 750 to 1499 Grams 386, 387 DRG 386 includes 765.03 to 765.05, DRG 387 includes 765.00
(5) Neonate Respiratory Distress Syndrome 386 Codes for DRG 386 except 76501-76505
LL. Prematurity with Major Problems

Prematurity with Major Problems 387 Codes for DRG 387 except 76500
MM. Prematurity without Major Problems

Weight > 1749 Grams 388
NN. Full Term Neonates

(1) With major problems (age 0) 389
(2) With other problems 390
Subp. 20g. Additional DRG requirements.
A. Version 23 of the Medicare grouper and DRG assignment to the diagnostic category must be used uniformly for all determinations of rates and payments.
B. The discharge status will be changed to "discharge to home" for DRG 433.
C. A diagnosis with the prefix "v57" will be excluded when grouping under subpart 20e.
D. The discharge status will be changed to "discharge to home" when grouping under subparts 20b and 20d for a transfer to a Medicare rehabilitation distinct part.
E. A transfer from subpart 20b or 20d, which included ICD-9-CM procedure code 86.06 (implantation of a totally implantable infusion pump) for the treatment of spasticity, to a Medicare rehabilitation distinct part must include ICD-9-CM diagnosis code 781.0 when grouping under subpart 20e.
F. Neonates transferred into a neonatal intensive care unit with a DRG assignment of DRG 482, 541, or 542, age less than one year, will be grouped under subpart 20f.
G. The discharge status will be changed to "discharge to home" for all neonates in DRG 385, except for neonates that expire at the birth hospital and the discharge date is the same as the date of birth.
H. For payment of admissions that result from a home health nurse being unavailable, and there is one or more acute episodes of illness during the admission resulting in changes in physician orders and the treatment plan, the principal diagnoses V58.89, other specified aftercare and V63.1, medical services in home not available will be excluded.
I. For neonates transferred into a neonatal intensive care unit within 28 days of birth, with a principal diagnosis of congenital anomaly (ICD-9-CM code 740-759) and a secondary diagnosis of conditions originating in the perinatal period (ICD-9-CM code 760-779), the principal diagnosis and the first sequenced secondary diagnosis in the range 760-779 will be interchanged when grouping under subpart 20f.
J. The admission source will be changed to "admitted as a transfer from another hospital" for neonates born before admission to the hospital and admitted directly to a Level IV neonatal intensive care unit.
K. For patients in DRG 386-390 and the age is greater than zero, the principal diagnosis from ICD-9-CM Chapter 15, certain conditions originating in the perinatal period (diagnoses codes 760-779), will be excluded when grouping under subparts 20b and 20d.
L. For payment under DRG 521, alcohol/drug abuse or dependence with complications or comorbidities, payment shall not be made for patients engaged in alcohol and/or drug rehabilitation.
M. The patient age will be changed to 18 years for DRG 003. If the admission subsequently groups to DRG 529 or 530, that DRG will be assigned. Otherwise the admission will remain in DRG 003.
N. The admission source will be changed to "admitted as a transfer from a different acute care hospital" for all newborns admitted to the hospital within the first 28 days after birth with a principal diagnosis of V29.0-V29.9.
O. The prematurity subcategory diagnosis codes 765.20 and 765.26 through 765.29 will be ignored when assigning a DRG if a diagnosis code from 764, 765.0, or 765.1 is not included on the claim.
Subp. 21. [Repealed, 18 SR 1115]
Subp. 22. General assistance medical care.

"General assistance medical care" means the program established by Minnesota Statutes, section 256D.03.

Subp. 23. [Repealed, 18 SR 1115]
Subp. 24. [Repealed, 18 SR 1115]
Subp. 24a. [Repealed, 18 SR 1115]
Subp. 25. Hospital.

"Hospital" means a facility defined in Minnesota Statutes, section 144.696, subdivision 3, and licensed under Minnesota Statutes, sections 144.50 to 144.581, or an out-of-state facility licensed to provide acute care under the requirements of the state in which it is located.

Subp. 26. Hospital cost index.

"Hospital cost index" means the factor annually multiplied by the allowable base year operating cost to adjust for cost changes.

Subp. 26a. Inpatient hospital costs.

"Inpatient hospital costs" means a hospital's base year inpatient hospital service costs determined allowable under the cost finding methods of Medicare, but not to include the medical assistance surcharge, without regard to adjustments in payments imposed by Medicare.

Subp. 27. Inpatient hospital service.

"Inpatient hospital service" means a service provided by or under the supervision of a physician after admission to a hospital and furnished in the hospital, including outpatient services provided by the same hospital that directly precede the admission.

Subp. 28. [Repealed, 18 SR 1115]
Subp. 28a. Local trade area hospital.

"Local trade area hospital" means a metropolitan statistical area hospital located outside Minnesota in a county contiguous to Minnesota that has 20 or more medical assistance admissions in the base year.

Subp. 28b. Long-term care hospital.

"Long-term care hospital" means a Minnesota hospital or a metropolitan statistical area hospital located outside Minnesota in a county contiguous to Minnesota that meets the requirements under Code of Federal Regulations, title 42, part 412, section 23(e).

Subp. 28c. Low volume local trade area hospital.

"Low volume local trade area hospital" means a metropolitan statistical area hospital located outside Minnesota in a county contiguous to Minnesota that has less than 20 medical assistance admissions in the base year.

Subp. 29. Medical assistance.

"Medical assistance" means the program established under Title XIX of the Social Security Act and Minnesota Statutes, sections 256.9685 to 256.9695 and chapter 256B. For purposes of parts 9500.1090 to 9500.1155, "medical assistance" includes general assistance medical care unless otherwise specifically stated.

Subp. 30. [Repealed, 18 SR 1115]
Subp. 30a. [Repealed, 18 SR 1115]
Subp. 31. Medicare.

"Medicare" means the federal health insurance program established under Title XVIII of the Social Security Act.

Subp. 32. Medicare crossover.

"Medicare crossover" means a claim submitted by a hospital to request payment for Medicare Part A covered inpatient hospital services provided to a patient who is also eligible for medical assistance.

Subp. 33. Metropolitan statistical area hospital.

"Metropolitan statistical area hospital" means a hospital located in a metropolitan statistical area as determined by Medicare for the October 1 prior to the most current rebased rate year.

Subp. 33a. [Repealed, 18 SR 1115]
Subp. 34. Nonmetropolitan statistical area hospital.

"Nonmetropolitan statistical area hospital" means a Minnesota hospital not located in a metropolitan statistical area as determined by Medicare for the October 1 prior to the most current rebased rate year.

Subp. 35. Operating costs.

"Operating costs" means inpatient hospital costs excluding property costs.

Subp. 36. [Repealed, 26 SR 976]
Subp. 37. Out-of-area hospital.

"Out-of-area hospital" means a hospital located outside Minnesota that is not a local trade area hospital or a low volume local trade area hospital.

Subp. 38. Property costs.

"Property costs" means inpatient hospital costs not subject to the hospital cost index, including depreciation, interest, rents and leases, property taxes, and property insurance.

Subp. 39. [Repealed, 18 SR 1115]
Subp. 40. [Repealed, 18 SR 1115]
Subp. 41. [Repealed, 18 SR 1115]
Subp. 41a. Rate year.

"Rate year" means a calendar year from January 1 to December 31.

Subp. 42. [Repealed, 18 SR 1115]
Subp. 43. [Repealed, 18 SR 1115]
Subp. 43a. [Repealed, 18 SR 1115]
Subp. 44. [Repealed, 18 SR 1115]
Subp. 44a. Rehabilitation distinct part.

"Rehabilitation distinct part" means inpatient hospital services that are provided by a hospital in a unit designated by Medicare as a rehabilitation distinct part.

Subp. 45. Relative value.

"Relative value" means the mean operating cost within a diagnostic category divided by the mean operating cost in all diagnostic categories within a program at subpart 20b or 20d or specialty group at subpart 20e or 20f.

Subp. 46. [Repealed, 18 SR 1115]
Subp. 47. [Repealed, 18 SR 1115]
Subp. 47a. [Repealed, 18 SR 1115]
Subp. 48. [Repealed, 18 SR 1115]
Subp. 49. [Repealed, 18 SR 1115]
Subp. 50. Transfer.

"Transfer" means the movement of a patient after admission from one hospital directly to another hospital with a different provider number or to or from a rehabilitation distinct part.

Subp. 51. Trim point.

"Trim point" means that number of inpatient days beyond which an admission is a day outlier.

Subp. 52. [Repealed, 18 SR 1115]

Notes

Minn. R. agency 196, ch. 9500, HOSPITAL MEDICAL ASSISTANCE REIMBURSEMENT, pt. 9500.1100
10 SR 227; 11 SR 987; 11 SR 1688; 12 SR 1617; 13 SR 1689; 14 SR 8; 14 SR 1005; 18 SR 1115; 19 SR 1191; 23 SR 1627; 25 SR 1021; 26 SR 976; 27 SR 1515; 31 SR 819

Statutory Authority: MS s 256.9685; 256.969; 256.9695

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.

No prior version found.