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296-23A-0460  <<  296-23A-0470 >>   296-23A-0480

Which exclusions and exceptions apply to diagnosis-related-group (DRG) payments for hospital services?

The following exclusions and exceptions apply to DRG payments for hospital services:
Psychiatric, rehabilitation, and chemical dependency (substance abuse) services will be excluded from payment by DRG rates. These services will be paid using per diem payment rates.
Ambulance and air transportation services are excluded from DRG payments.
Bills assigned to a DRG that is defined as ungroupable will be denied.
Bills where the principal diagnosis is invalid as a discharge diagnosis will be denied.
Bills where the injured worker has been admitted and discharged in less than twenty-four hours will be reviewed by the department and may be paid as hospital outpatient services.
The department may choose to exclude other DRGs from DRG payment rates due to concerns about access, case volume or other considerations. These services will be paid using the applicable percent of allowed charges (POAC) factor and per diem rates.
[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. WSR 97-06-066, § 296-23A-0470, filed 2/28/97, effective 4/1/97.]