HomeMy WebLinkAbout22- Personnel CITY OF SAN BERNARDIwO - REQUEST FOR COUNCIL AC) WN
From: Roger DeFratis , Actg Personnel Director Subject: Preferred Provider Agreement with Saint
Bernardine Hospital for Medical and Hos-
Dept: Personnel pital Care Benefits for Active and Retired
City Employees.
Date: February 22, 1988
Synopsis of Previous Council action:
None
Recommended motion:
Adont resolution.
Signature
Contact person: Roger DeFratis Phone: 5008
Supporting data attached: _ Ward: _
FUNDING REQUIREMENTS: Amount: N/A Source:
Finance:
Council Notes:
CIT . OF SAN BERNARDI`_, - REQUE, t FOR COUNCIL ACI - .)N
STAFF REPORT
The Personnel Office has been advised by the City Attorney' s
Office that Council approval is necessary when the City
enters into any agreement. In this case, St. Bernardine
Hospital is offering substantial discounts to the City and
it' s employees who utilize their services, and, in return,
the City merely has to identify St. Bernardine's as a
Preferred Provider to City employees and retirees covered
under the John Hancock Health Plan. These discounts average
between 15% to 25% of the usual charges for provided
services, and is expected to translate into an annual savings
of $60, 000 to $100, 000 to the City, depending on the usage by
employees.
i
RESOLUTION NO.
2
3 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
EXECUTION OF AN AMENDMENT TO THE PREFERRED PROVIDER AGREEMENT
4 WITH SAINT BERNARDINE HOSPITAL FOR MEDICAL AND HOSPITAL CARE
BENEFITS FOR ACTIVE AND RETIRED CITY EMPLOYEES.
5 BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE
6 CITY OF SAN BERNARDINO AS FOLLOWS:
?
SECTION 1. The Director of Personnel is hereby author-
8 ized and directed to execute on behalf of said City an
9 amendment to the Preferred Provider agreement with Saint
10 Bernardine Hospital , relating to employees ' medical and
11 hospital care benefits , effective January 1, 1988, which
12 agreement is attached hereto, marked Exhibit "A" , and
13 incorporated herein by reference as fully as though set
14 forth as length.
15 I HEREBY CERTIFY that the foregoing resolution was duly
16 adopted by the Mayor and Common Council of the City of San
17 Bernardino at a _ meeting thereof, held on
18 the of 1988, by the following vote
10 to wit:
20 AYES: Councilmembers _ _
21
22 NAYS: ----- -- --- —
23 ABSENT:
24
25
26 City Clerk -
27 (Continued)
28 Page
2-17-88
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2 The foregoing resolution is hereby approved this
3 day of , 1988.
4
5 Mayor of the City of San Bernardino _
6
7 Approved as to form and legal content:
,n
9 City Attorney
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28 2-17-88
AMENDMENT TO PREFERRED PROVIDER AGREEMENT
BETWEEN
CITY OF SAN BERNARDINO
AND
ST. BERNARDINE MEDICAL CENTER
The parties to the Preferred Provider Agreement entered into effective January
1, 1987, hereby amend the Hospital compensation rates as per new Exhibit "B"
attached herein by reference.
This Amendment shall be effective for health care services rendered on or
after January 1, 1988.
ST. BERNARDINE MEDICAL CENTER CITY OF SAN BERNARDINO
By: By:
Title: Administrator Title:
Date: _ Date:
By:
Title:
Date:
EXHIBIT "B"
PAYMENT SCHEDULE
Refer to Exhibit B.1, B.2, and B.3 attached.
THIS EXHIBIT IS EFFECTIVE FOR SERVICES RENDERED ON OR AFTER JANUARY 1, 1988.
CITY OF SAN BERNARDINO HOSPITAL
By: By:
Title: Title: Administrator
Date of Signature: Date of Signature:
By:
Title:
Date of Signature:
OWN
Exhibit 81 - Attachment I
DRG PER CASE
ST . BERNARDINE HOSPITAL
MEDICARE PROVIDER NO . 050129
Percentage of Charges
to be used
with DRG Per Case Rates
Category Proposed Percentage of Charges
DRG 468 DEATHS AND TRANSFERS 75 %
Outpatient Services 90 %
Emergency Room 90 %
Clinics 90 %
Ambulatory Surgery 90 %
Other Outpatient Service 90 %
NOTE : The proposed percentage discount for Outpatient
Services ( 90% ) reflects the fact that Outpatient
Services are already reduced from those applicable
to the rates proposed for Inpatient Services .
EXHIBIT B .2
PHYSICIAN PEES INCLUDED IN PAYMENT RATE
DEPARTMENT PROCEDURES
EKG EKG
Rhythm Strip
VCG ' s
CPR ' s
EEO EEG
OPG
CARDIOVASCULAR Echocardiograms
Stress Test ( Treadmill )
Pacemaker
Hotter Monitor
PULMONARY LAB Spirometry w/Bronch
Residual Air
Spirometry
Screening
DLCO
Exercise Tolerance
CARDIAC REIIABILITARION Stress Test ( Treadmill )
OUTPATIENT CLINIC Professional Pee
r
Exhibit B .3
ST . BERNARDINE HOSPITAL MEDICARE PROVIDER NO . 050129
SERVICES NOT AVAILABLE AT ST . BERNARDINE HOSPITAL
103 HEART TRANSPLANT
302 KIDNEY TRANSPLANT
351 STERILIZATION , MALE
359 TUBAL INTERRUPTION FOR NON-MALIGNANCY
362 LAPAROSCOPIC TUBAL INTERRUPTION
457 EXTENSIVE BURNS
PREFERRED PROVIDER AGREEMENT
THIS PREFERRED PROVIDER AGREEMENT is by and between City of San
Bernardino (hereinafter "City") , and St. Bernardine Medical Center, a
hospital licensed under the laws of the State of California (herein-
after "Hospital") .
I.
DEFINITIONS
1. 1 "Benefit Agreement" means the written or verbal contract
entered into between the City and its Employees that establishes City' s
obligations to its Employees for payment for medical, hospital, and
other health care benefits.
1. 2 "Employee" means any person who is covered under City's
Benefit Agreement.
II.
HOSPITAL PERFORMANCE PROVISIONS
2 . 1 Hospital shall provide those services that it customarily and
usually provides to the public. Hospital agrees (1) to not
differentiate or discriminate in the access to, treatment of, or
quality of services delivered to Employees on the basis or race, color,
national origin, sex, age, religion, ancestry, marital status, sexual
orientation, place of residence, health status, or source of payment
and (2) to render health services to all Employees in the same manner,
in accordance with the same standards and within the same time
availability as offered its other patients.
2 . 2 In no event is Hospital obligated to provide any services in
contravention of the Ethical and Religious Directive for Catholic
Health Facilities, a copy of which has been given to City and is
incorporated herein.
2 . 3 Exhibit "B" , which is the payment provision, shall indicate
what physician services are to be included in the rates of Exhibit "B" .
Except as affirmatively stated in Exhibit "B" , Hospital shall not be
responsible for assuring that Employees will be able to obtain
physician services, including hospital-based physician services.
2 . 4 Hospital hereby represents and warrants that it is currently,
and for the duration of this Agreement shall remain: (1) licensed as a
general acute care hospital in accardance with state licensing
provisions; (2) accredited by JCAH; and (3) certified as a Medicare and
Medicaid provider.
PREFERRED PROVIDER AGREEMENT
Between City of San Bernardino and St. Bernardine Medical Center
Page 2
III.
CITY PERFORMANCE PROVISIONS
3 . 1 City shall alter its Benefit Agreement to provide for
"Financial Incentives" for its Employees to use Hospital rather than
other hospitals in the area. Such "Financial Incentives" shall
provide, at a minimum that:
(a) There shall be no deductible amount owed by the Employee
when receiving medically necessary, covered hospital services from
Hospital, but there shall be at least a one hundred dollar
($100. 00) deductible when receiving such services from another
hospital ; and
(b) There shall be no coinsurance amount owed by the
Employee when receiving medically necessary, covered hospital
services from Hospital, but there shall be at least a ten percent
(10%) coinsurance amount when receiving such services from another
hospital.
3 . 2 City shall provide Hospital with the complete Benefit Agree-
ment and a summary statement of the Benefit Agreement. City shall
provide Hospital with any and all amendments, modifications, and
revisions to the Benefit Agreement that materially affect this Agree-
ment prior to the date such amendments, modifications, and revisions
become effective.
3 . 3 City shall supply Employees with an identification card or
other means of indicating coverage under the Benefit Agreement. City
shall also supply with the card or other method a phone number where
eligibility and coverage questions will be answered. Hospital shall
make a reasonable effort to confirm that the individual presenting an
identification card is in fact the individual whose name appears on the
identification card.
IV.
SERVICE LOCATION
Hospital shall provide health care services to Employees
within those facilities listed in Exhibit "A" . Hospital shall notify
City of any changes to Exhibit "A" prior to their effective date.
V.
PAYMENT
5. 1 Hospital shall accept the amounts specified in Exhibit "B" ,
which is attached hereto and incorporated herein, as ;full payment for
all health care services provided to Employees in accordance with the
Benefit Agreement, except where Hospital may bill and collect its usual
charges for the provision of non-covered and not medically necessary
services and coordination of benefit payments.
PREFERRED PROVIDER AGREEMENT
Between City of San Bernardino and St. Bernardine Medical Center
Page 3
5. 2 During the inital three year term of this Agreement, the per
diem rates stated in Exhibit B shall increase on the two annual anni-
versaries of the commencement of this Agreement by the same amount as
then most recently published California Hospital price Index but not
more than seven (7%) annually. This mechanism will continue into
renewal terms unless the parties agree otherwise.
5. 3 If an Employee requests services from Hospital that are not
covered or not medically necessary under the Benefit Agreement,
Hospital is entitled to enter into an agreement with the Employee to
provide such services at the Hospital ' s then usual charges.
5. 4 Hospital must accept assignment of benefits as a condition
precedent to City' s payment. Hospital may use its customary assignment
form. If an Employee refuses to assign a benefit claim upon the
Hospital ' s request and Hospital has reason to believe the Employee will
not honor the bill, Hospital may collect the amounts otherwise due from
City from the Employee at the time of service. Hospital may also
collect amounts for the provision of non-covered and not medically
necessary services at the time of service.
5. 5 Although City retains the right to review all claims (includ-
ing) inpatient, outpatient, emergency, or otherwise) retrospectively to
determine whether services rendered were covered by the Benefit Agree-
ment including retrospective review of whether the services were
medically necessary, City acknowledges and agrees that utilization
review and quality assurance determinations that services rendered were
not covered or medically necessary under the Benefit Agreement shall
not limit Hospital 's right to payment in full unless prior to
Hospital ' s rendition of such services (i) Hospital had reason to know
such services were not covered or medically necessary under the Benefit
Agreement, or (ii) Hospital was notfied that such services were not
covered or medically necessary under the Benefit Agreement. In no
event shall there be a retroactive denial of claims for (i) emergencies
as defined by the Benefit Agreement or (ii) services rendered for
approved admissions and lengths of stay. Hospital acknowledges and
agrees that Hospital shall not be paid for inpatient services furnished
past a Patient' s approved length of stay or approved extension thereof.
Nothing in this Agreement is intended to, nor shall be construed to
alter or otherwise restrict Hospital ' s right to conduct its own utili-
zation review for its own purposes.
VI.
BILLINGS
6. 1 Hospital shall submit all bills on its customary billing
forms and use its customary billing procedures. Billings shall include
identifying patient information, diagnosis, and itemized records of
services and charges even though the only amout due to Hospital by City
is the payment set forth in this Agreement.
PREFERRED PROVIDER AGREEMENT
Between City of San Bernardino and St. Bernardine Medical Center
Page 4
6. 2 Hospital shall submit its bills no later than thirty (30)
days after the service is rendered or the discharge of the Employee,
whichever is later. In the event Hospital is unable to submit bills
within the time specified herein because of circumstances beyond its
control, the time for submission of such bill shall be extended as
reasonably necessary from the date such bills would be required to be
submitted in the absence of such circumstances.
6 . 3 Pursuant to its usual procedures Hospital may bill the
Employee or responsible party for that portion of the Hospital charges
for which the Employee or responsible party is responsible.
6. 4 In the event City is a secondary payor under the Benefit
Agreement, City' s liability established by the rates of this Agreement
shall be reduced in accordance with the Benefit Agreement. It shall be
the responsibility of the Hospital to attempt to collect payment from
the primary payor, following the Hospital ' s customary collection
procedures with respect thereto and being free to bill the Hospital 's
then usual charges to the primary payor without being limited in such
collection by the rates agreed to under this Agreement. On the other
hand, if City is the primary payor and there is a secondary payor, the
Hospital may attempt to collect its usual charges from the secondary
payor without being limited in such collection by the rates agreed to
under this Agreement.
6. 5 Within fifteen (15) days of City' s receipt of Hospital ' s
completed bill and evidence of assignment, City shall pay (or cause to
be paid) or advise Hospital of the reason for nonpayment of the amount
due.
VII.
INDEPENDENT RELATIONSHIP
No provision of this Agreement is intended to create nor
shall be deemed or construed to create any relationship between City
and Hospital solely for the purpose of effecting the provisions of this
Agreement. Neither of the parties hereto, nor any of their respective
employees, shall be construed to be the joint venturer, partner, agent,
employee, or representative of the other.
VIII.
INSPECTION OF RECORDS AND AUDITS
8 . 1 Hospital shall maintain with respect to each Employee
receiving health care a hospital medical record in such form,
containing such information, and preserved for such time period(s) as
are required by the rules and regulations of the California Department
of Health, the federal Medicare Program, and the Joint Commission on
Accreditation of Hospitals.
PREFERRED PROVIDER AGREEMENT
Between City of San Bernardino and St. Bernardine Medical Center
Page 5
8 .2 It is understood that the medical records referred to in
Section 8. 1 above shall be and remain the property of Hospital and
shall not be removed or transferred from Hospital except in accordance
with applicable California and Federal law and regulations promulgated
thereto and Hospital rules and regulations. In accordance with
procedures required by law, Hospital shall permit City to inspect and
make copies of said records, and shll provide copies of such records to
City upon request. City shall reimburse Hospital for all reasonable
costs incurred by Hospital as a result of such record duplication.
8 . 3 City or its designated representative shall at City's own
cost and expense have the right to investigate and audit whether
Hospital 's bill accurately reflects the services actually provided.
Hospital shall cooperate with this audit by making available all
necessary files and records pertinent to the particular bill (s) being
audited as may be reasonably requested. Any such audit or investiga-
tion shall be carried out without requiring Hospital to reveal any
physician-patient confidential information not otherwise subject to
disclosure pursuant to law or the Employee's consent.
IX.
PROMOTION AND LISTING OF HOSPITAL
9. 1 City shall list the name, address and telephone number of
Hospital, provide a description of the facilities and services provided
by Hospital, and provide a description of the Financial Incentives for
Employees to use Hosptial under this Agreement in all communications
from City to its Employees regarding the Benefit Agreement.
9. 2 Nothing in this Agreement shall prohibit Hospital from
appealing to Employees through individual solicitation or general
public advertising to use Hospital rather than other providers as long
as City approved the solicitation or advertising and any applicable
governmental approval is obtained. To this end City will offer
reasonable cooperation (e.g. , Employee mailing lists) .
X.
TERM OF AGREEMENT
10. 1 The Term of this Agreement shall be for three (3) years
commencing on January 1, 1987, provided Hospital has the right upon at
least ninety (90) days written notice to terminate this Agreement, with
or without cause, effective on either of the two annual anniversaries
of this Agreement. This Agreement shall automatically renew on a year
to-year basis thereafter unless either party, with or without cause,
gives at least ninety (90) days written notice prior to the expiration
of the then current term.
PREFERRED PROVIDER AGREEMENT
Between City of San Bernardino and St. Bernardine Medical Center
Page 6
10. 2 As a conditon precedent to the City' s exercise of its right
during any renewal term to the without cause termination provision
under Section 10. 1 for the purpose of contracting with another hospital
provider located within the area set forth in Exhibit "C" , City shall
allow Hospital sixty (60) days to agree to prices no less favorable to
City than those offered by the other Hospital . If Hospital agrees to
accept those prices, Exhibit B of this Agreement shall be renewed to
incorporate such prices with all other terms remaining as set forth
herein and the City will not contract with the other hospital.
10 . 3 Either party shall have the right to terminate this Agreement
upon providing thirty (30) days prior written notice to the other party
if the Party to whom such notice is given materially breaches any
provision of this Agreement. The party claiming the right to terminate
hereunder shall set forth in the notice of intended termination
required hereby the facts underlying its claim that the other party is
in breach of this Agreement. Remedy of such breach within twenty (20)
days of the receipt of such notice shall revive the Agreement in effect
for the remaining term, subject to any other rights of termination
contained in this Paragraph or in any other provision of this Agree-
ment.
10. 4 As of the date of termination of this Agreement, this
Agreement shall be considered of no further force of effect whatsoever
and each of the parties shall be relieved and discharged herefrom,
except that:
A. Termination shall have no effect upon the rights and obliga-
tions of the parties arising out of any transactions occurring prior to
the effective date of such termination.
B. Hospital and City shall remain liable for any obligations or
liabilities arising from activities carried on by such party or its
agents, servants, or employees during the period this Agreement shall
have been in effect.
C. In the event an Employee is an admitted inpatient of Hosptial
as of the date of termination of this Agreement, Hospital reimbursement
for services rendered during the period the Employee remains as an
admitted inpatient of Hospital will continue to be governed by the
applicable terms of this Agreement. Hospital shall be compensated in
accordance with this Agreement for all health care services rendered by
Hospital to an Employee on the date of the termiantion of this Agree-
ment and until such time as appropriate transfer or discharge (or other
medically acceptable disposition) of Employees receiving inpatient
services on the date of termination is completed.
PREFERRED PROVIDER AGREEMENT
Between City of San Bernardino and St. Bernardine Medical Center
Page 7
XI .
NOTICES
Any notice required to be given pursuant to the terms and
provisions hereof, unless otherwise indicated herein, shall be in
writing and shall be sent by certified mail, return receipt requested,
postage prepaid, to the addresses listed below. Notices shall be
deemed received upon receipt by the addressee.
XII.
MODIFICATIONS
It is the express intention of City and Hospital that the
terms of this totally integrated writing shall comprise the entire
Agreement between the parties and it shall not be subject to
rescission, modification, or waiver except as defined in a subsequent
written instrument executed by both parties hereto. In furtherance of
this Agreement, City and Hospital mutually covenant and request of any
reviewing tribunal that any claim of rescission, modification, or
waiver predicated upon any evidence other than a subsequent written
instrument executed by the parties hereto shall be regarded as void.
XIII .
ASSIGNABILITY
Neither this Agreement nor any right hereunder shall be
assigned, transferred, or otherwise conveyed by either party without
the prior written acceptance of the other.
XIV.
PARTICIPATION IN ALTERNATIVE HEALTH CARE PROGRAMS
Nothing contained in this Agreement shall prevent Hospital
from participating in or contracting with any insurer, preferred
provider organization, health maintenance organization, or otherwise
entering into contracts regarding health care delivery with any other
entity. During the term of this Agreement however, City agrees that
with the exception of contracts for services that the Hospital will not
perform under the Ethical and Religious Directives for Catholic Health
Facilities, City will not contract with any hospital provider of health
care services that is physically located within the geogrpahic area
defined by Exhibit C, attached hereto and incorporated herein. If,
during the term of this Agreement or any extension thereof, the
Hospital 's service area is expanded, Hospital shall have a right of
first refusal to be the exclusive provider of covered services and
benefits to patients within the expanded service area on terms no less
favorable to City than are available from other providers of covered
services and benefits. If, prior to the expansion of the Hospital 's
service area, however, City has executed contracts with one or more
providers of covered services and benefits within the expanded service
i
0
PREFERRED PROVIDER AGREEMENT
Between City of San Bernardino and St. Bernardine Medical Center
Page 8
area, Hospital shall have the right to contract with and to provided
covered services and benefits to patients within such area on a
nonexclusive basis under terms no less favorable to Hospital than to
the other hospital.
XV.
INVALIDITY OR UNENFORCEABILITY
The invalidity or unenforceability of any terms or provisions
hereof shall in no way affect the validity or enforceability of any
other term or provision.
XVI .
THIRD PARTY BENEFICIARIES
Hospital and City agree that Employees to whom health care
services are provided by Hospital and for which Hospital is compensated
hereunder shall not be third party beneficiaries of the rights and
obligations assumed by either party hereto.
XVII.
BUSINESS INTERRUPTION
In the event the operations of either party' s facilities or
any substantial portion thereof are interrupted by war, fire, insurrec-
tion, labor troubles, riots, the elements, earthquakes, acts of God,
or, without limiting the foregoing, any other cause beyond their power,
each provision of this Agreement that is rendered incapable of per-
formance shall be suspended for the duration of such interruption. If
a substantial part of the services which either party has agreed to
provide is interrupted for a period in excess of sixty (60) days,
however, the other party shall have the right to terminate this
Agreement upon twenty (20) days ' written notice.
XVII.
WAIVER
The informal toleration by either party of defective per-
formance of any provision of this Agreement shall not be construed as a
waiver of either the right to performance or the express conditions
which have been created in this Agreement.
XIX.
COUNTERPARTS
This Agreement may be executed in counterparts, each of which
shall be deemed to be an original, but all of which together shall
constitute one and the same agreement.
7
LLF Draft: 11/5/86
THIS AGREEMENT SHALL BE EFFECTIVE F R HEALTH CARE SERVICES REN-
DERED ON OR AFTER: J 1
ST. BERNARDINE "�Rkj&L 5'^13> CITY OF SAN BERNARDINO
MEDICAL CENTER
By• A By-
Tit e: Title:
Date of Signature: Date o 4Sigt4ure:
2101 Address-
A
loll N. Waterman Avenue �
San Bernardino, CA 92404
(714)883-8711 ne:
FFF6417/7
ato 2• V~
10
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ST. BERNARDINE MEDICAL CENTER MEDICAT ROVIDER NO. : 050129 EXHIBIT 1/88
DRG PER CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (DRG2) RATE/CASE
DRG 001 CRANIOTOMY AGE )=18 EXCEPT FOR TRAUMA f 13,995
DRG 002 CRANIOTOMY FOR TRAUMA AGE )=18 f 9,993
DRG 003 CRANIOTOMY AGE (18 f 752
DRG 004 SPINAL PROCEDURES f 10,559
DRG 005 EXTRACRANIAL VASCULAR PROCEDURES f 8,016
DRG 006 CARPAL TUNNEL RELEASE S 75%
DRG 007 PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC AGE )=70 AND/OR C.C. f 75%
1DRG 008 PERIPH & CRANIAL NERVE 5 OTHER NERV SYST PROC AGE (70 W/O C.C. f 75%
DRG 009 SPINAL DISORDERS & INJURIES f 75%
DRG 010 NERVOUS SYSTEM NEOPLASMS AGE )=70 AND/OR C.C. f 6,983
DRG O11 NERVOUS SYSTEM NEOPLASMS AGE (70 W/O C.C. f 75%
DRG 012 DEGENERATIVE NERVOUS SYSTEM DISORDERS f 3,990
DRG 013 MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA f 75%
DRG 014 SPECIFIC CEREBROVASCULAR DISORDERS EXECEPT TIA f 7, 148
DRG 015 TRANSIENT ISCHEMIC ATTACKS f 2,976
DRG 016 NONSPECIFIC CEREBROVASCULAR DISORDERS WITH C.C. f 75%
DRG 017 NONSPECIFIC CEREBROVASCULAR DISORDERS W/O C.C. f 75%
DRG 018 CRANIAL & PERIPHERAL NERVE DISORDERS AGE )= 70 AND/OR C.C. f 16,217
DRG 019 CRANIAL & PERIPHERAL NERVE DISORDERS AGE (7- W/O C.C. f 75%
DRG 020 NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS f 6,463
DRG 021 VIRAL MENINGITIS f 75%
DRG 022 HYPERTENSIVE ENCEPHALOPATHY f 75%
DRG 023 NONTRAUMATIC STUPOR & COMA f 75%
DRG 024 SEIZURE & HEADACHE AGE )=70 AND/OR C.0 f 5,097
DRG 025 SEIZURE & HEADACHE AGE 18-69 W/O C.C. f 1,807
DRG 026 SEIZURE & HEADACHE AGE 0-17 f 75%
DRG 027 TRAUMATIC STUPOR & COMA, COMA )lHR f 75%
DRG 028 TRAUMATIC STUPOR & COMA, COMA (1 HR AGE )=70 AND/OR C.C. f 75%
DRG 029 TRAUMATIC STUPOR & COMA (1 HR AGE 18-69 W/O C.C. f 75%
DRG 030 TRAUMATIC STUPOR & COMA (1 HR AGE 0-17 f 752
DRG 031 CONCUSSION AGE )=10 AND/OR C.C. f 75%
DRG 032 CONCUSSION AGE 18-69 W/O C.C. f 115%
DRG 033 CONCUSSION AGE 0-17 f 75%
DRG 034 OTHER DISORDERS OF NERVOUS SYSTEM AGE )=70 AND/OR C.C. f 75%
DRG 035 OTHER DISORDERS OF NERVOUS SYSTEM AGE (70 W/O C.C. f 75%
DRG 036 RETINAL PROCEDURES $ 3,982
DRG 037 ORBITAL PROCEDURES f 75%
DRG 038 : PRIMARY IRIS PROCEDURES f 752
DRG 039 LENS PROCEDURES f 75%
DRG 040 EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE )=18 f 75%
DRG 041 EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0-17 f 75%
DRG 042 INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS f 3, 141
DRG 043 HYPHEMIA f 75%
DRG 044 ACUTE MAJOR EYE INFECTIONS f 75%
DRG 045 NEUROLOGICAL EYE DISORDERS f 75%
DRG 046 OTHER DISORDERS OF THE EYE AGE )=18 W/O C.C. f 75%
DRG 047 OTHER DISORDERS OF THE EYE AGE )=70 AND/OR CC f 75%
DRG 048 OTHER DISORDERS OF THE EYE AGE 0-17 f 75%
DRG 049 MAJOR HEAD & NECK PROCEDURES f 13,860
DRG 050 SIALOADENECTOMY f 75%
ST. BERNARDINE MEDICAL CENTER MED 'E PROVIDER NO. : 050129 EXHIF 1/29/88
DRG PER CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (DRG2) RATE/CASE
DRG 051 SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY f 75%
DRG 052 CLEFT LIP & PALATE REPAIR f 751
DRG 053 SINUS & MASTOID PROCEDURES AGE )=18 f 75%
DRG 054 SINUS & MASTOID PROCEDURES AGE 0-17 f 751
DRG 055 MISCELLANEOUS EAR, NOSE & THROAT PROCEDURES f 75%
DRG 056 RHINOPLASTY f 751
DRG 057 T&A PROC EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY AGE )=18 f 751
'DRG 058 T&A PROC EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY AGE 0-17 f 751
DRG 059 TONSILLECTOMY AND/OR ADENOIDECTORMY AGE )=18 f 752
ORG 060 TONSILLECTOMY AND/OR ADENOIDECTOMY 0-17 f 751
DRG 061 MYRINGOTOMY AGE )=18 f 75%
DRG 062 MYRINGOTOMY AGE 0-17 f 751
DRG 063 : OTHER EAR, NOSE & THROAT O.R. PROCEDURES f 751
DRG 064 : EAR, NOSE & THROAT MALIGNANCY f 75%
DRG 065 DYSEAUILIBRIUM f 75%
ORG 066 EPISTAXIS f 75%
DRG 067 EPIGLOTTITIS f 75%
DRG 068 : OTITIS MEDIA & URI AGE )=10 AND/OR C.C. f 75%
DRG 069 OTITIS MEDIA & URI AGE 18-69 W/O C.C. f 751
DRG 070 OTITIS MEDIA & URI AGE 0-17 f 751
DRG 071 LARYNGOTRACHEITIS f 751
DRG 072 : NASAL TRAUMA & DEFORMITY f 75%
DRG 073 OTHER EAR, NOSE & THROAT DIAGNOSES AGE )=18 f 751
DRG 074 OTHER EAR, NOSE & THROAT DIAGNOSES AGE 0-17 f 751
DRG 075 MAJOR CHEST PROCEDURES f 14,574
DRG 076 O.R. PROC OF THE RESP SYSTEM EXCEPT MAJOR CHEST WITH C.C. f 11,099
DRG 077 O.R. PROC OF THE RESP SYSTEM EXCEPT MAJOR CHEST W/O C.C. f 75%
DRG 078 : PULMONARY EMBOLISM f 5,907
DRG 079 RESPIRATORY INFECTIONS & INFLAMMATIONS AGE )=70 AND/OR C.C. f 18,539
DRG 080 RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 18-69 W/O C.C. f 751
DRG 081 RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 0-17 f 751
ORG 082 RESPIRATORY NEOPLASMS f 5,850
DRG 083 MAJOR CHEST TRAUMA AGE (=70 AND/OR C.C. f 751
DRG 086 MAJOR CHEST TRAUMA AGE (70 W/O C.C. f 751
DRG 085 PLEURAL EFFUSION AGE )=70 AND/OR C.C. f 5,075
DRG 086 PLEURAL EFFUSION AGE (70 W/O C.C. f 751
DRG 087 PULMONARY EDEMA & RESPIRATORY FAILURE f 9,828
DRG 088 : CHRONIC OBSTRUCTIVE PULMONARY DISEASE f 9,172
DRG 089 SIMPLE PNEUMONIA & PLEURISY AGE )=70 AND/OR C.C. f 8, 174
DRG 090 SIMPLE PNEUMONIA & PLEURISY AGE 18-69 W/O C.C. f 4,130
DRG 091 SIMPLE PNEUMONIA & PLEURISY AGE 0-17 f 2,104
DRG 092 INTERSTITIAL LUNG DISEASE AGE )=70 AND/OR C.C. f 5,686
DRG 093 INTERSTITIAL LUNG DISEASE AGE (70 W/O C.C. f 751
DRG 096 PNEUMOTHORAX AGE )=70 AND/OR C.C. f 6,502
DRG 095 PNEUMOTHORAX AGE (70 W/O C.C. f 751
DRG 096 BRONCHITIS & ASTHMA AGE ):70 AND/OR C.C. f 5,929
DRG 097 BRONCHITIS & ASTHMA AGE 18-69 W/O C.C. f 4,049
DRG 098 BRONCHITIS & ASTHMA AGE 0-17 f 2,216
DRG 099 RESPIRATORY SIGNS & SYMPTOMS AGE )70 AND/OR C.C. f 3,884
DRG 100 RESPIRATORY SIGNS & SYMPTOMS AGE (70 W/O C.0 f 751
ST. BERNARDINE MEDICAL CENTER MED' RE PROVIDER NO. : 050129 EXHIP" 1/29/88
ORG PER CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (DRG2) RATE/CASE
DRG 101 OTHER RESPIRATORY DIAGNOSES AGE )=70 AND/OR C.C. f 6,849
DRG 102 OTHER RESPIRATORY DIAGNOSES AGE (70 f 751
DRG 103 HEART TRANSPLANT $ N/A
DRG 104 CARDIAC VALVE PROCEDURE WITH PUMP & CARDIAC CATH f 36,380
DRG 105 CARDIAC VALVE PROCEDURE WITH PUMP & W/O CARDIAC CAOTH 1 23, 179
DRG 106 CORONARY BYPASS WITH CARDIAC CATH 1 21,308
DRG 107 CORONARY BYPASS W/O CARDIAC CATH $ 17,266
'DRG 108 CARDIOTHOR PROC. EXCEPT VALVE A CORONARY BYPASS, WITH PUMP f 6,601
DRG 109 CARDIOTHORACIC PROCEDURES W/0 PUMP $ 8,625
DRG 110 MAJOR RECONSTRUCTIVE VASCULAR PROCEDURES AGE )=70 AND/OR C.C. 2 17,731
DRG 111 MAJOR RECONSTRUCTIVE VASCULAR PROCEDURES AGE (70 WIO C.C. 1 9,795
DRG 112 VASCULAR PROCEDURES EXCEPT MAJOR RECONSTRUCTION S 9,237
DRG 113 AMPUTATION FOR CIRC SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE 1 9,721
DRG 114 UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS f 9,535
DRG 115 PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI OR CHF S 20,609
DRG 116 PERMANENT CARDIAC PACEMAKER IMPLANT W/O AMI OR CHF f 13,810
DRG 117 CARDIAC PACEMAKER REPLACE & REVIS EXC PULSE GEN REPL ONLY f 751
DRG 118 CARDIAC PACEMAKER PULSE GENERATOR REPLACEMENT ONLY % 7,189
DRG 119 ; VEIN LIGATION & STRIPPING 1 751
DRG 120 OTHER O.R. PROCEDURES ON THE CIRCULATORY SYSTEM s 31,083
DRG 121 CIRCULATORY DISORDERS WITH AMI & C.Y. COMP. DISCH. ALIVE t 9,485
ORG 122 CIRCULATORY DISORDERS WITH AMI W/O C.V. COMP. DISCH. ALIVE 1 4,423
DRG 123 CIRCULATORY DISORDERS WITH AMI, EXPIRED 1 8,451
DRG 124 CIRCULATORY DISORDERS EXC AMI, WITH CARD CATH & COMPLEX DIAG 1 3,239
DRG 125 CIRCULATORY DISORDERS EXC AMI, WITH CARD CATH W/O COMPLEX DIAG f 2,274
DRG 126 ACUTE & SUBACUTE ENDOCARDITIS = 75%
DRG 127 HEART FAILURE & SHOCK f 51880
ORG 128 DEEP VEIN THROMBOPHLEBITIS S 4,959
DRG 129 CARDIAC ARREST f 75%
DRG 130 PERIPHERAL VASCULAR DISORDERS AGE )=70 AND/OR C.C. $ 3,877
DRG 131 PERIPHERAL VASCULAR DISORDERS AGE (70 W/O C.C. 1 751
DRG 132 ATHEROSCLEROSIS AGE )=70 AND/OR C.C. S 3,486
DRG 133 ATHEROSCLEROSIS AGE (70 W/O C.C. 1 751
DRG 134 HYPERTENSION f 2,230
DRG 135 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE )=70 AND/OR C.C. f 751
DRG 136 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 18-69 W/O C.C. i 751
DRG 137 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 0-17 f 751
DRG 138 ; CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS AGE )=70 AND/OR C.C. f 3,919
DRG 139 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE (70 W/O C.C. f 2,547
DRG 140 ANGINA PECTORIS 3 2,749
DRG 141 SYNCOPE & COLLAPSE AGE )=70 AND/OR C.C. $ 3,308
DRG 142 SYNCOPE & COLLAPSE AGE (70 W/O C.C. f 751
DRG 143 : CHEST PAIN 1 2,584
DRG 144 OTHER CIRCULATORY DIAGNOSES WITH C.C. $ 8,227
DRG 145 OTHER CIRCULATORY DIAGNOSES W/O C.C. $ 751
DRG 146 RECTAL RESECTION AGE )=70 AND/OR C.C. $ 16,824
DRG 147 RECTAL RESECTION AGE (70 W/O C.C. 1 75%
DRG 148 MAJOR SMALL & LARGE BOWEL PROCEDURES AGE )=70 AND/OR C.C. $ 15,176
DRG 149 MAJOR SMALL & LARGE BOWEL PROCEDURES AGE )70 AND/OR C.C. i 7,902
DRG 150 PERITONEAL ADHESIOLYSIS AGE )=70 AND/OR C.C. f 11,451
ST. BERNARDINE MEDICAL CENTER MEDI PROVIDER NO. : 050129 EXHIB /29/88
DRG PER CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (DRG2) RATE/CASE
DRG 151 PERITONEAL ADHESIOLYSIS AGE (70 W/O C.C. f 7. 193
DRG 152 MINOR SMALL & LARGE BOWEL PROCEDURES AGE )=70 AND/OR C.C. f 752
DRG 153 MINOR SMALL & LARGE BOWEL PROCEDURES AGE (7- W/O C.C. f 752
DRG 154 STOMACH, ESOPHAGEAL 5 DUODENAL PROCEDURES AGE )=70 AND/OR C.C. i 12,648
DRG 155 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 18-69 WIO C.C. f 5,707
DRG 156 STOMACH, ESOPHAGEAL 5 DUODENAL PROCEDURES AGE 0-17 t 75%
DRG 157 ANAL PROCEDURES AGE )=70 AND/OR CC f 3,843
'ORG 158 ANAL PROCEDURES AGE (70 W/O C.C. f 2,329
DRG 159 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE )=70 AND/OR C.C. f 5,178
ORG 160 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE 18-69 E/0 C.C. f 2,556
DRG 161 INGUINAL & FEMORAL HERNIA PROCEDURES AGE )=70 AND/OR C.C. f 752
DRG 162 : INGUINAL & FEMORAL HERNIA PROCEDURES AGE 18-69 W/O C.C. f 1,829
DRG 163 HERNIA PROCEDURES AGE 0-17 f 752
DRG 164 APPENDECTOMY WITH COMPLICATED PRINC. DIAG AGE )=70 AND/OR C.C. f 13,794
DRG 165 APPENDECTOMY WITH COMPLICATED PRINC. DIAG AGE (70 W/O C.C. f 5,150
ORG 166 APPENDECTOMY W/O COMPLICATED PRINC. DIAG AGE )=70 W/O C.C. f 752
DRG 167 APPENDECTOMY WIO COMPLICATED PRINC. DIAG AGE (70 W/O C.C. S 3, 105
DRG 168 PROCEDURES ON THE MOUTH AGE )=70 AND/OR C.C. f _2
DRG 169 PROCEDURES ON THE MOUTH AGE (70 W/O C.C. f 3,772
DRG 170 OTHER DIGESTIVE SYSTEM PROCEDURES AGE )=70 AND/OR C.C. f 6,809
DRG 171 OTHER DIGESTIVE SYSTEM PROCEDURES AGE (70 W/O C.C. f 752
DRG 172 DIGESTIVE MALIGNANCY AGE )70 AND/OR C.C. f 6,223
DRG 173 DIGESTIVE MALIGNANCY AGE (70 W/O C.C. f 752
DRG 174 G. I. HEMORRHAGE AGE )= 70 AND/OR C.C. f 4,242
DRG 175 G. I. HEMORRHAGE AGE (70 W/O C.C. f 752
DRG 176 COMPLICATED PEPTIC ULCER f 6,157
DRG 177 UNCOMPLICATED PEPTIC ULCER )=10 AND/OR C.C. f 758
DRG 178 UNCOMPLICATED PEPTIC ULCER (70 W/O C.C. f 752
DRG 179 INFLAMMATORY BOWEL DISEASE f 752
DRG 180 : G. I. OBSTRUCTION AGE )=70 AND/OR C.C. f 3,678
DRG 181 G. I. OBSTRUCTION AGE (70 W/O C.C. f 752
DRG 182 ESOPHAGITIS, GASTROENT. & MISC. DIGEST. DIS AGE )=70 &/OR C.C. f 3,186
DRG 183 ESOPHAGITIS, GASTROENT. 5 MISC. DIGEST. DIS AGE 18-69 W/O C.C. f 1,954
DRG 184 ESOPHAGITIS, GASTROENTERITIS & MISC. DIGEST. DISORDERS AGE 0-17 f 1,329
DRG 185 DENTAL & ORAL DIS. EXC EXTRACTIONS & RESTORATIONS, AGE )=18 f 752
DRG 186 DENTAL & ORAL DIS. EXC EXTRACTIONS & RESTORATIONS, AGE 0-17 f 752
DRG 187 DENTAL EXTRACTIONS & RESTORATIONS f 752
DRG 188 OTHER DIGESTIVE SYSTEM DIAGNOSES AGE )=70 AND/OR C.C. f 5,683
DRG 189 OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 18-69 W/O C.C. f 752
DRG 190 OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0-17 f 752
DRG 191 MAJOR PANCREAS, LIVER & SHUNT PROCEDURES f 9,132
DRG 192 MINOR PANCREAS, LIVER & SHUNT PROCEDURES f 752
DRG 193 BILIARY TRACT PROC EXC TOT CHOLECYSTECTOMY AGE )=70 &/OR C.C. f 14,286
DRG 194 BILIARY TRACT PROC EX TOT CHOLECYSTECTOMY AGE (70 OR C.C. f 752
DRG 195 TOTAL CHOLECYSTECTOMY WITH C.D.E. AGE )=70 AND/OR C.C. f 9,508
DRG 196 TOTAL CHOLECYSTECTOMY WITH C.D.E. AGE (70 W/O C.C. f 752
DRG 197 TOTAL CHOLECYSTECTOMY W/O C.D.E. AGE )=70 AND/OR C.C. f 5,744
DRG 198 TOTAL CHOLECYSTECTOMY W/O C.D.E. AGE (70 W/O C.C. f 4,250
DRG 199 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY f 752
DRG 200 H£PATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY f 11,556
ST. BERNARDINE MEDICAL CENTER MED ?E PROVIDER NO. : 050129 EXHIP'4%1/29/88
DRG PER CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (DRG2) RATE/CASE
DRG 201 OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES f 9,684
DRG 202 CIRRHOSIS A ALCOHOLIC HEPATITIS S 4,437
DRG 203 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS f 5,719
DRG 204 DISORDERS OF PANCREAS EXCEPT MALIGNANCY f 4,97;
DRG 205 DISORDERS OF LIVER EXC MALIG, CIRR, ALC HEPA AGE (70 W/O C.C. f 7,362
ORG 206 DISORDERS OF LIVER EXC MALIG, CIRR, ALC HEPA AGE 00 W/O C.C. f 752
DRG 207 DISORDERS OF THE BILIARY TRACT AGE )=70 AND/OR C.C. f 752
'DRG 208 DISORDERS OF THE BILIARY TRACT AGE (70 W/O C.C. f 752
DRG 209 : MAJOR JOINT PROCEDURES f 10,769
DRG 210 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE )=70 AND/OR C.C. 1 9,583
ORG 211 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 18-69 W/O C.C. f 7,278
DRG 212 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0-17 f 752
DRG 213 AMPUTATIONS FOR MUSCULOSKELETAL SYSTEM & CONN. TISSUE DISORDERS f 752
DRG 214 BACK & NECK PROCEDURES AGE )=70 AND/OR C.C. f 7,270
DRG 215 BACK & NECK PROCEDURES AGE (70 W/O C.C. f 4,878
ORG 216 BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE f 752
DRG 217 WND DEBRID & SKIN GRFT EX HAND, FOR MUSCSKELETAL & CONN. TISS. DIS f 752
ORG 218 LOWER EXTREM & HUMER PROC EXC HIP, FOOT, FEMUR AGE )=70 &/OR C.C. f 7,514
DRG 219 LOWER EXTREM & HUMER PROC EX HIP, FOOT, FEMUR AGE 18-69 W/O C.C. f 5,196
ORG 220 LOWER EXTREM & HUMER PROC EXC HIP, FOOT, FEMUR AGE 0-17 f 75t
DRG 221 KNEE PROCEDURES AGE )=70 AND/OR C.C. f 752
DRG 222 KNEE PROCEDURES AGE (70 W/O C.C. f 2,607
DRG 223 UPPER EXTREMITY PROC HUMERUS & HAND AGE )=70 AND/OR C.C. f 752
ORG 224 UPPER EXTREMITY PROC EXC HUMERUS & HAND AGE (70 W/O C.C. f 2,795
DRG 225 FOOT PROCEDURES f 2,544
DRG 226 SOFT TISSUE PROCEDURES AGE )=70 AND/OR C.C. f 752
DRG 227 SOFT TISSUE PROCEDURES AGE (70 W/O C.C. f 752
DRG 228 GANGLION (HAND) PROCEDURES $ 752
DRG 229 HAND PROCEDURES EXCEPT GANGLION f 752
DRG 230 LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR f 752
DRG 231 LOCAL EXCISION & REMOVAL OF INT FIX DEVICES EXCEPT HIP & FEMUR f 2,726
DRG 232 ARTHROSCOPY f 752
DRG 233 OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC AGE )=70 &/OR C.C. f 5,375
DRG 234 OTHER MUSCULOSKELET SYST & CONN TISS O.R. PROC AGE (70 W/O C.C. f 3,009
DR6 235 FRACTURES OF FEMUR f 752
DRG 236 : FRACTURES OF HIP & PELVIS $ 4,906
DRG 237 SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS, & THIGH f 75%
DRG 238 OSTEOMYELITIS $ 752
DRG 239 PATHOLOGICAL FRACTURES & MUSCULOSKELETAL & CONN. TISS. MALIGNANCY f 3,907
DRG 240 CONNECTIVE TISSUE DISORDERS AGE )=70 AND/OR C.C. f 752
DRG 241 CONNECTIVE TISSUE DISORDERS AGE 00 W/O C.C. f 752
DRG 242 SEPTIC ARTHRITIS i 752
DRG 243 MEDICAL BACK PROBLEMS f 2,054
DRG 244 BONE DISEASES & SEPTIC ARTHROPATHY AGE )=10 AND/OR C.C, f 752
DRG 245 BONE DISEASES & SEPTIC ARTHROPATHY AGE (70 W/O C.C. f 752
DRG 246 NON-SPECIFIC ARTHROPATHIES f 752
DRG 247 SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE f 2,590
DRG 248 TENDONITIS, MYOSITIS & BURSITIS f 752
DRG 249 AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE f 752
ORG 250 FX, SPRNS, STRNS, & DISL OF FOREARM, HAND, FOOT AGE )=70 AND/OR C.C. f 752
ST. BERNARDINE MEDICAL CENTER MEDT' °E PROVIDER NO. : 050129 EXHIB" 1/29/88
DRG PER CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (DRG2) RATE/CASE
DRG 251 FX, SPRNS, STRNS, & DISL OF FOREARM, HAND, FOOT AGE 18-69 W/O C.C. f 752
DRG 252 FX, SPRNS, STRNS, & DISL OF FOREARM, HAND, FOOT AGE 0-17 1 75%
DRG 253 FX, SPRNS, STRNS, & DISL OF UPARM, LOWLEG EX FOOT AGE )=10 &/OR C.C. 1 2,388
DRG 254 FX, SPRNS, STRNS 5 DISL OF UPARM, LOWLEG EX FOOT AGE 18-69 W/O C.C. f 75%
DRG 255 FX, SPRNS, STRNS, & DISL OF UPARM, LOWLEG EX FOOT AGE 0-17 1 752
DRG 256 OTHER DIAGNOSES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE $ 752
DRG 257 TOTAL MASTECTOMY FOR MALIGNANCY AGE )=70 AND/OR C.C. f 3,803
'ORG 258 TOTAL MASTECTOMY FOR MALIGNANCY AGE (70 W/O C.C. f 752
DRG 259 SUBTOTAL MASTECTOMY FOR MALIGNANCY AGE )=70 AND/OR C.C. S 752
DRG 260 SUBTOTAL MASTECTOMY FOR MALIGNANCY AGE (70 $ 752
DRG 261 BREAST PROC FOR NON-MALIG EXCEPT BIOPSY & LOC EXC $ 752
DRG 262 BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY $ 752
DRG 263 SKIN GRAFTS FOR SKIN ULCER OR CELLULITIS AGE )=70 AND/OR C.C. $ 8,577
DRG 264 SKIN GRAFTS FOR SKIN ULCER OR CELLULITIS AGE (70 W/O C.C. S 752
DRG 265 SKIN GRAFTS EXCEPT FOR SKIN ULCER OR CELLULITIS WITH C.C. $ 752
DRG 266 SKIN GRAFTS EXCEPT FOR SKIN ULCER OR CELLULITIS W/O C.C. $ 752
DRG 267 PERIANAL & PILONIDAL PROCEDURES $ 752
DRG 268 SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES $ 752
DRG 269 OTHER SKIN, SUBCUT TISS & BREAST O.R. PROC AGE )=70 OR C.C. f 5,189
DRG 270 OTHER SKIN, SUBCUT TISS & BREAST O.R. PROC AGE )70 W/O C.C. f 752
DRG 271 SKIN ULCERS $ 752
DRG 272 MAJOR SKIN DISORDER AGE )=70 AND/OR C.C. 1 752
DRG 273 MAJOR SKIN DISORDERS AGE (70 W/O C.C. t 752
DRG 274 MALIGNANT BREAST DISORDERS AGE )=10 AND/OR C.C. 1 752
DRG 275 MALIGNANT BREAST DISORDERS AGE (70 W/O C.C. f 752
DRG 276 NON-MALIGNANT BREAST DISORDERS 1 752
DRG 277 CELLULITIS AGE )70 &/OR C.C. f 4,661
DRG 278 CELLULITIS AGE 18-69 W/O C.C. f 3,366
DRG 279 CELLULITIS AGE 0-17 S 752
DRG 280 TRAUMA TO THE SKIN, SUBCUT TISS 5 BREAST AGE )=10 &/OR C.C. $ 752
DRG 281 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 18-69 W/O C.C. t 752
DRG 282 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0-17 S 752
DRG 283 MINOR SKIN DISORDERS AGE )=70 AND/OR C.C. 1 752
DRG 284 MINOR SKIN DISORDERS AGE (70 W/O C.C. f 752
DRG 285 AMPUTATIONS FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS 1 18,368
DRG 286 ADRENAL & PITUITARY PROCEDURES 1 752
DRG 287 SKIN GRAFTS & WOUND DEBRIDE FOR ENDOC, NUTRIT & METAB DISORDERS f 752
DRG 288 O.R. PROCEDURES FOR OBESITY 1 752
DRG 289 PARATHYROID PROCEDURES f 752
DRG 290 THYROID PROCEDURES $ 752
DRG 291 THYROGLOSSAL PROCEDURES f 752
DRG 292 OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC AGE )70 6/OR C.C. S 11,418
DRG 293 OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC AGE (70 W/O C.C. $ 752
DRG 294 ; DIABETES AGE )=36 1 3,586
DRG 295 DIABETES AGE 0-35 $ 2,408
DRG 296 NUTRITIONAL & MISC. METABOLIC DISORDERS AGE )=70 AND/OR C.C. 1 5,205
DRG 297 NUTRITIONAL & MISC. METABOLIC DISORDERS AGE 18-69 W/O C.C. S 752
DRG 298 NUTRITIONAL & MISC. METABOLIC DISORDERS AGE 0-17 S 752
DRG 299 INBORN ERRORS OF METABOLISM $ 752
DRG 300 ENDOCRINE DISORDERS AGE )=70 AND/OR C.C. $ 752
ST. BERNARDINE MEDICAL CENTER MEDIi PROVIDER NO. : 050129 EXHIBI,.J/29188
ORG PER. CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (DRG2) RATE/CASt
DRG 301 ENDOCRINE DISORDERS AGE )70 W/0 C.C. f 75%
DRG 302 KIDNEY TRANSPLANT $ N/A
DRG 303 KIDNEY, URETER 6 MAJOR BLADDER PROCEDURE FOR NEOPLASM $ 9,973
ORG 304 KIDNEY, URETER 6 MAJ BLDR PROC FOR NON-MALIG AGE )=70 6/OR C.C. $ 91151
DRG 305 : KIDNEY, URETER 5 MAJ BLDR PROC FOR NON-MALIG AGE (70 W/O C.C. f 5,555
ORG 306 PROSTATECTOMY AGE )=70 AND/OR C.C. 1 7,975
DRG 307 PROSTATECTOMY AGE (70 W/O C.C. $ 75%
DRG 308 MINOR BLADDER PROCEDURES AGE ):10 AND/OR C.C. S 75%
DR6 309 MINOR BLADDER PROCEDURES AGE (70 W/O C.C. 1 752
ORG 310 TRANSURETHRAL PROCEDURES AGE )=70 AND/OR C.C. S 3,010
DRG 311 : TRANSURETHRAL PROCEDURES AGE (70 W/O C.C. S 75%
DRG 312 URETHRAL PROCEDURES, AGE )=70 AND/OR C.C. S 75%
DRG 313 URETHRAL PROCEDURES, AGE 18-69 W/O C.C. S 752
DRG 314 URETHRAL PROCEDURES, AGE 0-17 f 75%
DRG 315 OTHER KIDNEY 6 URINARY TRACT O.R. PROCEDURES S 9,427
DRG 316 RENAL FAILURE W/O DIALYSIS 1 6,840
DRG 317 RENAL FAILURE WITH DIALYSIS $ 75%
DRG 318 KIDNEY A URINARY TRACT NEOPLASMS AGE )=70 AND/OR C.C. 3 75%
DRG 319 KIDNEY 6 URINARY TRACT NEOPLASMS AGE (70 W/O C.C. f 75%
DRG 320 : KIDNEY 6 URINARY TRACT INFECTIONS AGE )= 70 AND/OR C.C. f 4,846
DRG 321 KIDNEY 6 URINARY TRACT INFECTIONS AGE 18-69 W/O C.C. S 2,777
DRG 322 KIDNEY 6 URINARY TRACT INFECTIONS AGE 0-17 1 75%
DRG 323 URINARY STONES AGE )=10 AND/OR C.C. f 75%
DRG 324 URINARY STONES AGE (70 W/O C.C. 1 75%
DRG 325 KIDNEY 6 URINARY TRACT SIGNS 6 SYMPTOMS AGE )=70 AND/OR C.C. 1 75%
DRG 326 KIDNEY 6 URINARY TRACT SIGNS 6 SYMPTOMS AGE 18-69 W/O C.C. E 75%
DRG 327 KIDNEY 6 URINARY TRACT SIGNS 6 SYMPTOMS AGE 0-17 $ 75%
ORG 328 : URETHRAL STRICTURE AGE )=70 AND/OR C.C. $ 75%
DRG 329 URETHRAL STRICTURE AGE 18-69 W10 C.C. $ 752
DRG 330 : URETHRAL STRICTURE AGE 0-17 1 75%
DRG 331 OTHER KIDNEY 6 URINARY TRACT DIAGNOSES AGE )=70 AND/OR C.C. $ 75%
DRG 332 OTHER KIDNEY 6 URINARY TRACT DIAGNOSES AGE 18-69 W/O C.C. $ 75%
DRG 333 OTHER KIDNEY 6 URINARY TRACT DIAGNOSES AGE 0-17 $ 75%
DRG 334 MAJOR MALE PELVIC PROCEDURES WITH C.C. S 10,882
DRG 335 MAJOR MALE PELVIC PROCEDURES W/O C.C. f 75%
DRG 336 TRANSURETHRAL PROSTATECTOMY AGE )=70 AND/OR C.C. f 4,293
DRG 337 TRANSURETHRAL PROSTATECTOMY AGE (70 W/O C.C. f 75%
DRG 338 TESTES PROCEDURES, FOR MALIGNANCY $ 75%
DRG 339 TESTES PROCEDURES, NON-MALIGNANT AGE )=18 1 75%
DRG 340 TESTES PROCEDURES, NON-MALIGNANT AGE 0-17 $ 75%
DRG 341 PENIS PROCEDURE S 75%
DRG 342 CIRCUMCISION AGE )=18 Z 75%
DRG 343 CIRCUMCISION AGE 0-17 S 75%
DRG 344 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY $ 75%
DRG 345 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY $ 75%
DRG 346 MALIGNANCY, MALE REPRODUCTIVE SYSTEM, AGE )=70 AND/OR C.C. 1 75%
DRG 347 MALIGNANCY, MALE REPRODUCTIVE SYSTEM, AGE (70 W/O C.C. $ 75%
DRG 348 BENIGN PROSTATIC HYPERTROPHY AGE )=70 AND/OR C.C. $ 75%
DRG 349 BENIGN PROSTATIC HYPERTROPHY AGE (70 W/O C.C. $ 75%
DRG 350 INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM f 75%
ST. BERNARDINE MEDICAL CENTER MED' E PROVIDER NO. : 050129 EXHIO/29/88
DRG PER CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (ORG2) RATE/CASE
DRG 351 STERILIZATION, MALE f N/A
ORG 352 OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES f 753
DRG 353 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & VULVECTOMY f 753
DRG 354 NON-RADICAL HYSTERECTOMY AGE )10 AND/OR C.C. f 6,276
DRG 355 NON-RADICAL HYSTERECTOMY AGE (70 W/O C.C. f 3,655
DRG 356 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES f 4,348
DRG 357 : UTERUS & ADENEXA PROCEDURES, FOR MALIGNANCY S 753
'DRG 358 UTERUS & ADENEXA PROC FOR NON-MALIGNANCY EXCEPT TUBAL INTERRUPT S 3,124
DRG 359 TUBAL INTERRUPTION FOR NON-MALIGNANCY f N/A
DRG 360 VAGINA, CERVIX & VULVA PROCEDURES f 753
DRG 361 LAPAROSCOPY & ENDOSCOPY (FEMALE) EXCEPT TUBAL INTERRUPTION f 2,161
DRG 362 LAPAROSCOPIC TUBAL INTERRUPTION f N/A
DRG 363 D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY f 753
DRG 364 0&C, CONIZATION EXCEPT FOR MALIGNANCY f 753
DRG 365 OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES f 4,096
DRG 366 MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM )=70 AND OR/C.C. f 752
DRG 367 MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM AGE (70 W10 C.C. f 753
DRG 368 INFECTIONS, FEMALE REPRODUCTIVE SYSTEM f 2,562
DRG 369 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS f 753
DRG 370 CESAREAN SECTION WITH C.C. f 31539
DRG 371 CESAREAN SECTION W/O C.C. f 2,876
DRG 372 VAGINAL DELIVERY WITH COMPLICATING DIAGNOSES f 1,538
DRG 373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSIS f 1,146
DRG 374 VAGINAL DELIVERY WITH STERILIZATION AND/OR 0&C f 753
DRG 375 VAGINAL DELIVERY WITH O.R. PROC EXCEPT STERIL AND/OR D&C f 753
DRG 376 : POSTPARTUM DIAGNOSIS W/O O.R. PROCEDURE f 753
DRG 377 POSTPARTUM DIAGNOSES WITH O.R. PROCEDURE f 752
ORG 378 ECTOPIC PREGNANCY f 2,704
DRG 379 : THREATENED ABORTION f 753
DRG 380 ABORTION W/O D&C f 753
DRG 381 ABORTION WITH D&C f 1,439
DRG 382 FALSE LABOR f 753
DRG 383 : OTHER ANTEPARTUM DIAGNOSIS WITH MEDICAL COMPLICATIONS f 1,646
DRG 384 OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS f 1,741
DRG 385 NEONATES, DIED OR TRANSFERRED f 753
ORG 386 EXTREME IMMATURITY, NEONATE $ 4,671
DR6 387 PREMATURITY WITH MAJOR PROBLEMS f 4,601
DRG 388 PREMATURITY W/O MAJOR PROBLEMS f 1,481
DRG 389 FULL TERM NEONATE WITH MAJOR PROBLEMS f 828
DRG 390 NEONATES WITH OTHER SIGNIFICANT PR08LEMS f 527
DRG 391 NORMAL NEWBORNS f 349
DRG 392 SPLENECTOMY AGE )=18 f 8,637
DRG 393 SPLENECTOMY AGE 0-17 f 753
DRG 394 OTHER O.R. PROCEDURES OF THE BLOOD & BLOOD FORMING ORGANS f 753
DRG 395 RED BLOOD CELL DISORDERS AGE )=18 f 5,183
DRG 396 RED BLOOD CELL DISORDERS AGE 0-17 f 753
DRG 397 COAGULATION DISORDERS f 5,266
ORG 398 RETICULOENDOTHELIAL & IMMUNITY DISORDERS AGE )=70 AND/OR C.C. f 753
DRG 399 RETICULOENDOTHELIAL & IMMUNITY DISORDERS AGE (70 W/O C.C. f 753
DRG 400 LYMPHOMA OR LEUKEMIA WITH MAJOR O.R. PROCEDURE 1 9,338
ST. BERNARDINE MEDICAL CENTER MEDI PROVIDER NO. : 050129 EXHIB ./29188
DRG PER CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (DRG2) RATE/CASE
DRG 401 LYMPHOMA OR LEUKEMIA WITH MINOR O.R. PROC AGE )=70 AND/OR C.C. f 752
DRG 402 LYMPHOMA OR LEUKEMIA WITH MINOR O.R. PROCEDURE AGE (70 W/O C.C. f 752
DRG 403 LYMPHOMA OR LEUKEMIA AGE )=10 AND/OR C.C. S 16,400
DRG 404 LYMPHOMA OR LEUKEMIA AGE 18-69 W/O C.C. S 18,468
DRG 405 LYMPHOMA OR LEUKEMIA AGE 0-17 f 75%
DRG 406 MYELOPROLIF DISORD OR POORLY DIFF NEOPLASM W MAJ O.R. PROC 6 C.C. f 21,764
DRG 407 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W/O C.C. s 752
DRG 408 MYELOPROLIF DISORD OR POORLY DIFF NEOPL WITH MINOR O.R. PROC s 752
DRG 409 RADIOTHERAPY f 752
DRG 410 CHEMOTHERAPY f 2,477
DRG 411 HISTORY OF MALIGNANCY W/O ENDOSCOPY S 752
DRG 412 HISTORY OF MALIGNANCY WITH ENDOSCOPY f 752
DRG 413 OTHR MYELOPROLIF DISORD OR POORLY DIFF NEOPL DX AGE )=70 6/OR C.C. f 6,186
DRG 414 OTHR MYELOPROLIF DISORD OR POORLY DIFF NEOPL DX AGE (70 W/O C.C. f 751
DRG 415 O.R. PROCEDURE FOR INFECTIOUS 6 PARASITIC DISEASE S 19,669
DRG 416 5EPTECEMIA AGE )=18 $ 10,329
DRG 417 SEPTICEMIA AGE 0-17 s 752
DRG 418 POSTOPERATIVE 6 POST-TRAUMATIC INFECTIONS f 6,543
DRG 419 FEVER OF UNKNOWN ORIGIN AGE )=70 AND/OR C.C. f 4,293
DRG 420 FEVER OF UNKNOWN ORIGIN AGE 18-69 W/O C.C. $ 752
DRG 421 VIRAL ILLNESS AGE )=18 s 3,217
DRG 422 VIRAL ILLNESS 6 FEVER OF UNKNOWN ORIGIN AGE 0-17 S 752
DRG 423 OTHER INFECIOUS 6 PARASITIC DISEASES DIAGNOSES • f 10,313
DRG 424 O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS i 752
DRG 425 ACUTE ADJUST REACT 6 DISTURBANCES OF PSYCHOSOCIAL DYSFUNCTION S 4,213
DRG 426 DEPRESSIVE NEUROSES f 5,469
DRG 427 : NEUROSES EXCEPT DEPRESSIVE f 4,059
ORG 428 : DISORDERS OF PERSONALITY 6 IMPULSE CONTROL f 752
ORG 429 ORGANIC DISTURBANCES 6 MENTAL RETARDATION f 4,611
DRG 430 PSYCHOSES f 6,804
DRG 431 CHILDHOOD MENTAL DISORDERS f 7,116
DRG 432 OTHER DIAGNOSES OF MENTAL DISORDERS S 752
DRG 433 SUBSTANCE USE 6 SUBST INDUCED ORGANIC MENTAL DISORDERS, LEFT AMA $ 752
DRG 434 : DRUG DEPENDENCE $ 75%
DRG 435 DRUG USE EXCEPT DEPENDENCE s 752
DRG 436 ALCOHOL DEPENDENCE s 752
DRG 437 ALCOHOL USE EXCEPT DEPENDENCE s 752
DRG 438 ALCOHOL 6 SUBSTANCE INDUCED ORGANIC MENTAL SYNDROME f 752
DRG 439 SKIN GRAFTS FOR INJURIES f 752
DRG 440 WOUND DEBRIDEMENTS FOR INJURIES f 752
DRG 441 HAND PROCEDURES FOR INJURIES f 752
DRG 442 OTHER O.R. PROCEDURES FOR INJURIES AGE )=70 AND/OR C.C. S 9,449
DRG 443 OTHER O.R. PROCEDURES FOR INJURIES AGE (70 W/O C.C. f 5,125
DRG 444 MULTIPLE TRAUMA AGE )=70 AND/OR C.C. s 752
DRG 445 MULTIPLE TRAUMA AGE 18-69 W/O C.C. f 752
DRG 446 MULTIPLE TRAUMA AGE 0-17 f 752
DRG 447 ALLERGIC REACTIONS AGE )=18 f 752
DRG 448 ALLERGIC REACTIONS AGE 0-17 f 752
DRG 449 TOXIC EFFECTS OF DRUGS AGE )=70 AND/OR C.C. f 3,524
DRG 450 TOXIC EFFECTS OF DRUGS AGE 18-69 W/O C.C. s 2,691
ST. BERNARDINE MEDICAL CENTER MED.,ARE PROVIDER NO. : 050129 EXHIu,, 1/29/88
ORG PER CASE RATES
PROPOSED
DIAGNOSIS RELATED GROUP (DRG2) RATE/CASE
DRG 451 TOXIC EFFECTS OF DRUGS AGE 0-17 S 752
DRG 452 COMPLICATIONS OF TREATMENT AGE )=70 AND/OR C.C. $ 4,977
DRG 453 COMPLICATIONS OF TREATMENT AGE (70 W/O C.C. t 752
DRG 454 OTHER INJURIES, POISONINGS 8 TOXIC EFF DIAG AGE )=70 AND/OR C.C. $ 752
DRG 455 OTHER INJURIES, POISONINGS 8 TOXIC EFF DIAG AGE )7O W/O C.C. t 752
DRG 456 BURNS, TRANSFERRED TO ANOTHER ACUTE CARE FACILITY 1 752
DRG 457 EXTENSIVE BURNS I N/A
DRG 458 NON-EXTENSIVE BURNS WITH SKIN GRAFTS $ 752
DRG 459 NON-EXTENSIVE BURNS WITH WOUND DEBRIDEMENT 6 OTHER O.R. PROC f 752
DRG 460 NON-EXTENSIVE BURNS W/O C.C. PROCEDURE $ 752
DRG 461 O.R. PROC WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES f 752
DRG 462 REHABILITATION f 752
DRG 463 SIGNS 6 SYMPTOMS WITH C.C. f 752
DRG 464 SIGNS & SYMPTOMS W/O C.C. $ 752
DRG 465 AFTERCARE WITH HISTORY OF MALIGNANCY AS SECONDARY DX i 752
DRG 466 AFTERCARE W/O HISTORY OF MALIGNANCY AS SECONDARY DX $ 752
DRG 467 OTHER FACTORS INFLUENCING HEALTH STATUS f 752