APR-DRG Weights and ALOS for Acute Services

Note: The version (v#) displayed above pertains to the 3M All Patient Refined Diagnosis Related Groups (APR-DRG) that will be utilized for the payment of the Medicaid, Workers Compensation and No-Fault rates.

Effective for discharges on or after July 1, 2018, version 34 of the 3M All Patient Refined Diagnosis Related Groups (APR-DRG) grouper will be utilized for Medicaid, Workers Compensation and No-Fault. The Department of Health has completed the rate rebasing initiative, effective July 1, 2018, and the development of the applicable 2018 service intensity weights (SIWs), average lengths-of-stays (ALOS) and cost outlier thresholds, which are also effective July 1, 2018.

Effective for discharges on or after October 1, 2015, version 33 of the 3M All Patient Refined Diagnosis Related Groups (APR-DRG) will be utilized for Medicaid, Workers Compensation and No-Fault. Since there are no changes to the APR-DRGs in v33 as compared to v31 and v32, the APR-DRG weights and outlier thresholds that were effective July 1, 2014 will remain in effect for the payment of these claims. Please refer to "Final APR-DRG Weights effective July 1, 2014 (version 31)" for the weights and outlier thresholds utilized effective October 1, 2015.

In addition, since the grouping is developed by 3M using clinical logic, if a claim does not group to an APR-DRG as the provider expects it to group, the provider will need to contact 3M to discuss the grouping logic. If 3M does determine, based on their clinical review, that the grouping should be revised, the Department is requesting the provider submit an email to hospffsunit@health.ny.gov informing the Department about the grouping logic discussion with 3M and the outcome for informational purposes.

Effective for discharges on or after July 1, 2014, version 31 of the 3M All Patient Refined Diagnosis Related Groups (APR-DRG) will be utilized for Medicaid, Workers Compensation and No-Fault. The Department of Health has completed the rate rebasing initiative, effective July 1, 2014, and the development of the applicable 2014 service intensity weights (SIWs), average lengthofstays (ALOS) and cost outlier thresholds, which are also effective July 1, 2014. The Department will implement the new SIWs effective for all 2014 acute discharges that were processed beginning July 1, 2014 at the time the fee-for-service Medicaid acute rates are approved by the Division of the Budget. Further information will be supplied at that time. The 2014 SIWs, ALOS, and cost outlier thresholds will not be implemented retroactively to January 1, 2014.

The presentation to the hospitals on July 10, 2014, regarding Acute Hospital Inpatient rates is published on the "Presentations" section of this web site. To view this and other presentations, select the "Presentations" button on the leftside navigation bar of this page.

For discharges beginning January 1, 2014 through June 30, 2014, the 2013 SIWs, cost thresholds and ALOS will be used for payment purposes with version 30 of the APR-DRG grouper. Refer to the "Final APR-DRG Weights effective January 1, 2014 (version 30)" link above for further information.

Effective for discharges on or after January 1, 2013, version 30 of the 3M All Patient Refined Diagnosis Related Groups (APR-DRG) will be utilized for Medicaid, Workers Compensation and No-Fault. The Department of Health has completed the development of the applicable 2013 service intensity weights (SIWs), average length-of-stays and cost outlier thresholds, which are also effective January 1, 2013. The Department implemented the new SIWs effective for all 2013 acute discharges that were processed beginning on November 22, 2013. Further, all previously paid 2013 claims were reprocessed with the January 1, 2013 and April 1, 2013 hospital inpatient rates that were approved by the Division of the Budget and loaded into the eMedNY system on November 28, 2013. This reprocessing also utilized the 2013 SIWs for the period January 1, 2013 through November 28, 2013.

Effective for discharges on or after January 1, 2012, version 29 of the 3M All Patient Refined Diagnosis Related Groups (APR-DRG) will be utilized for Medicaid, Workers Compensation and No-Fault. The Department of Health has completed the development of the applicable 2012 service intensity weights (SIWs), average length-of-stays and cost outlier thresholds, which are also effective January 1, 2012. The Department implemented the new SIWs effective for all 2012 acute discharges that were processed beginning on March 1, 2012. Further, all previously paid 2012 claims were reprocessed with the January 1, 2012 hospital inpatient rates that were recently approved by the Division of the Budget and loaded into the eMedNY system on October 4, 2012. This reprocessing also utilized the 2012 SIWs for the period January 1, 2012 thru February 29, 2012.

Effective October 1, 2010

These weights will also be utilized with the implementation of ICD-10 effective October 1,2015 - (Web) - (PDF)

Effective for Services Beginning:

October 1, 2021

October 1, 2019

October 1, 2015 [Updated 4/5/2016]

October 1, 2010 through September 30, 2015
Effective beginning October 20, 2010

The Centers for Medicare and Medicaid approved State Plan Amendment 10-03 which establishes a new psychiatric inpatient reimbursement method effective October 20, 2010 for general hospitals and replaces a per diem payment method based on 1981 costs trended. This new method was established in order to pay more appropriately for inpatient psychiatric admissions and address length of stay variances. The formula on which these new psychiatric exempt unit rates are promulgated is in accordance with Article 28 of the Public Health Law set forth in Part 86-1.39 of the Commissioner of Health´s Rules and Regulations.

The components of the new psychiatric methodology will include the use of psychiatric APR-DRGs, a statewide price (adjusted for wage differences), capital costs and direct medical education costs. The new methodology will also include payment factors based on rural hospital status, patient age, presence of mental retardation, co-morbidities, length of stay and a separate payment for electroconvulsive (ECT) treatment.

The presentation to hospitals on September 13, 2010, regarding Psychiatric Reform rates is published on the "Presentations" section of this web site. To view this and other presentations, select the "Presentations" button on the left-side navigation bar of this page.

July 1, 2013 Medicaid Update: New Inpatient Psychiatric Reimbursement Methodology