Table of Contents
Hospitals and Ambulatory
Surgery Centers
Methodology for Charges – InterQuartile Ranges
Background
Many insurance plans have traditionally utilized a standard deviation
based methodology for the development of outlier thresholds for
inpatient services. Due to the fact that the distribution of
hospital days within any DRG category is not normally distributed, the
interquartile range is an approach that does not rely on statistics
based upon a normal distribution and would offer a more technically
sound alternative. The interquartile range is a measurement
commonly used for working with nonparametric data as a means of
delivering more defensible results.
Rationale
The distribution of facility data is nonparametric in that variables
such as length of stay, costs, and charges have more variation at the
highend of the data sets. This means that the distribution
of data above the median value produces a much flatter curve than that
below the median value. Figure 1 graphically depicts the
differences between parametric and nonparametric distributions of data.
The interquartile range represents the width of an
interval which contains the middle fifty percent of the hospital
data. The interquartile range, therefore, is a distance, not
an interval, and it is a measure of the spread of the data.
Because of this it is less affected by high outliers in the data
set. Using the interquartile range methodology discounts the
impact that large outlier values have on measuring the dispersion of
data variables. For the type of data being analyzed, it is a
more stable statistic than the standard deviation.
Methodology
The interquartile range represents the width of an
interval which contains the middle fifty percent of the data; stated
alternatively, since 25% of the data are less than or equal to the
first quartile and 25% are greater than or equal to the third quartile,
the interquartile range is the length of an interval that includes
about half of the data. This difference is measured in the
same unit as the data.
To determine the interquartile range, all data are
organized from least to greatest value. The first quartile,
denoted as Q1, is the set of data having the property that at least
onequarter of the observations are less than or equal to Q1 and that
at least threequarters of the data are greater than or equal to
Q1. The third quartile, denoted as Q3, is conversely
identified.
To determine the interquartile range (IQR), the spread
of the difference between Q1 and Q3 is measured:
IQR = Q3  Q1 Top of Page
Hospitals
Methodology for Adjusting Length of Stay
The data is risk adjusted for patient severity in order
to allow for meaningful comparisons. The primary reason for risk
adjustment is to remove the longstanding and valid criticism that
evaluative comparisons of two or more disparate groups based on
observed reported data is often not an effective methodology due to
differences in casemix between the groups under study. This criticism
in simpler terms is the "our patients are sicker than their patients"
response.
In order to understand how data is adjusted for severity
and case mix, three concepts must be introduced; observed value,
expected value, and risk adjusted.
Observed Value
This is the reported value. For example, the observed
average length of stay for a hospital is calculated by taking the total
inpatient days for all patients and dividing this total by the total
number of cases. The values used for days and cases are taken from
information reported by the hospital to the Agency for Health Care
Administration (AHCA).
Expected Value
Expected values are severity adjusted according to case
mix, using 3M's All Patient Refined Diagnosis Related Groups (APRDRGs)
as the methodology for severity adjustment.
Note: Expected value calculations for adults are APRDRG
and age group specific for each product line age group. Expected value
calculations for pediatrics are APRDRG and age group specific for each
product line age group. Also, the values for pediatrics are based on
three years of data.
Before proceeding to an example of an expected value
calculation, we need to first describe the APRDRG patient
classification and severity assignment process.
Medicare DRGs and APRDRGs are patient classification
systems with a primary objective of grouping types of patients treated
by the resources they consume. 3M's APRDRGs build upon these systems
by going beyond the simple assignment of a base DRG by also assigning
to each case a severity of illness, defined as:
Severity of illness: the extent of
physiologic decompensation or organ system loss of function
Severity of illness subclasses are numbered as either 1
(minor), 2 (moderate), 3 (major), or 4 (extreme).
Assignment of severity of illness subclasses is based
upon a number of factors, including the underlying base APRDRG
assignment (determined by principal diagnosis, procedures, age, sex and
discharge status), secondary diagnoses, and interactions amongst
diagnoses.
The advantage of APRDRGs is that they acknowledge
differences in severity of illness among patients within a single
APRDRG, as fits with our real world understanding. For example, some
pneumonia patients are much sicker than others, even though they may
all be classified under the same DRG.
So how does this website use APRDRGs in calculating
expected values? Each inpatient case is assigned an expected value
which is the average value for that case's designated APRDRG and
severity of illness level across the State of Florida. For example, a
case is designated as a Simple Pneumonia (APRDRG 139) with a severity
of illness level 2. The state average length of stay for all Simple
Pneumonia (APRDRG 139) with severity of illness level 2 is 5.5 days.
The expected value for this specific case's length of stay would then
be 5.5 days.
Calculations:
Hospital's Observed ALOS:
Total hosp. days for the selected condition / total
hosp. cases for the selected condition
Hospital's Expected ALOS:
Average of the expected hosp. length of stay for all
cases for the selected condition at the hospital
Risk Adjusted Value
The riskadjusted average length of stay is the best
estimate, based on the statistical model, of what the provider's length
of stay would have been if the provider had a mix of patients identical
to the statewide mix. The risk adjusted value is the observed length of
stay divided by the expected length of stay and multiplied by the state
of Florida's average length of the stay for a medical
condition/procedure.
Hospital's Risk adjusted ALOS:
Observed ALOS for the selected condition / Expected ALOS
for the selected condition * State ALOS for the selected condition =
Risk Adjusted ALOS
Top of Page
Methodology for Potentially Preventable Readmissions
(PPRs) and APRDRGs:
Statistical Methods
Introduction
The 3M™ APR™ DRG version 31 classification
system categorizes patients based on their severity of illness and risk
of mortality.
Potentially Preventable Readmission (PPRs) identify
return hospitalizations that may have resulted from the process of care
and treatment (readmission for a surgical wound infection) or lack of
post admission followup (prescription not filled) rather than
unrelated events that occur post admission (broken leg due to trauma).
In computing a hospital PPR rate, the numerator is
defined as the number of initial admissions with one or more qualifying
clinically related readmissions within a given time period.
The denominator of a readmission rate is identified as the number of
initial admissions at risk for a potentially preventable readmission,
excluding deaths and admission meeting the criteria for one or more
global exclusions occurring in the index hospitalization, for the
related population for the same time period.
the number of initial
qualifying admissions with one or more PPRs
divided by
the number of admissions
at risk for a PPR
Rates of PPR occurrence can be calculated for each APRDRG
category by severity of illness level. A PPR rate for
each APRDRG by severity level was developed for each of these three
age groups based on a 15 day readmission window for readmissions across
hospitals. These rates are typically referred to as norms
because they reflect the experience of groups of hospitals.
Using APRDRG categories to control differences in the
clinical characteristics between their patients or those of the norm,
individual hospitals can compare their PPR rates to those of the
normative data. These comparisons will enable them to determine if and
how their performance differs from comparable hospitals. A
provider’s experiences and those of normative populations are
likely to be different. This can represent a true difference or can be
caused by normal variation. Statistical techniques can be used to
determine which of the observed differences in outcomes are most likely
to be true differences and which are probably the result of natural
variation.
Observed Value
The observed readmission rates are calculated for each
condition or procedure by dividing the number of initial discharges
with one or more Potentially Preventable Readmissions, PPRs, by the
total number of initial discharges. The AHCA normative database (state
values) are calculated for each APRDRG and severity of illness
subclass the same. The PPR is calculated as follows:
Let:
N = observed rate
P = Number of initial discharges with one or more PPRs
D = Number of initial discharges at risk for a PPR
i = condition or procedure or an APR DRG category and a single severity
of illness level
_{
}
This number is displayed as PPRs per initial discharge
to facilitate the calculations in the expected value computation
example below.
Expected Values
The expected value of PPRs is the number of readmission
chains (initial discharge with a PPR) a hospital, given its mix of
patients as defined by APRDRG category and severity of illness level,
would have experienced had its rate of PPRs been identical to that
experienced by a reference or normative set of hospitals.
The technique by which the expected value or expected
number of PPRs is calculated is called indirect standardization. For
illustrative purposes, assume that every initial discharge can meet the
criteria for having a PPR, a condition called being “at
risk” for a PPR. All initial discharges will either have no
PPRs or will have a chain of one and possibly more PPRs.
Once a set of PPR normative rates has been calculated by
APRDRG by SOI, it can be applied at the APRDRG and SOI level to
individual hospitals to compute the expected PPR rate for the
hospital. Then the PPR expected rate is adjusted for age over
85 and the presence of a major mental health problem as a comorbid
condition. These adjustments were computed from the AHCA normative
database for each of the three age groups.
Example
Age and Mental Health PPR Rate Adjustment Factors
Condition 
Age < 85 
Age >= 85 
Major Mental Health 
1.6394 
1.5058 
All Other 
0.9435 
1.1157 
Consider the following example for computing a
hospital’s expected PPR rate. For each APRDRG by
severity subclass, a normative PPR rate has been computed from the
normative database. Hospital AAA has 11 initial discharges in
the database. One of these initial discharges was globally
excluded from the PPR computations because the patient left against
medical advice. Of the remaining 10 initial discharges, one
of these initial discharges had a potentially preventable readmission
within the defined readmission window. The other nine initial
discharges either did not have a subsequent admission within the
defined readmission window or there was a subsequent readmission within
the defined readmission window, however, the readmission was not
identified as potentially preventable and therefore clinically excluded
from being considered a PPR.
Example
Normative PPR Rates
APRDRG

Severity
Level 
Normative
PPR Rate 
1 
1 
5.2 
1 
2 
6.4 
1 
3 
6.9 
1 
4 
7.3 
2 
1 
7.2 
2 
2 
8.9 
2 
3 
9.1 
2 
4 
9.9 
Example
Hospital Patient Discharge Readmission Data
Provider

APRDRG
 Severity Level 
Age

Major
Mental Health Condition 
Initial
Discharge At Risk for PPR 
Initial
Discharge With a PPR 
Normative
PPR Rate 
MH
& Age Adjusted Normative PPR Rate 
AAA 
1
– 4 
87 
Y 
Y 
Y 
7.3 
10.99 
AAA 
1
– 3 
89 
N 
Y 
N 
6.9 
7.70 
AAA 
2
– 4 
70 
Y 
Y 
N 
9.9 
16.23 
AAA 
1
– 2 
45 
Y 
N 
N 




AAA 
1
– 1 
35 
N 
Y 
N 
5.2 
4.91 
AAA 
2
– 1 
46 
N 
Y 
N 
7.2 
6.80 
AAA 
2
– 2 
88 
Y 
Y 
N 
8.9 
13.40 
AAA 
2
– 3 
23 
Y 
Y 
N 
9.1 
14.92 
AAA 
1
– 3 
85 
N 
Y 
N 
6.9 
7.70 
AAA 
2
– 4 
65 
Y 
Y 
N 
9.9 
16.23 
AAA 
2
– 3 
55 
Y 
Y 
N 
9.1 
14.92 
The provider's actual PPR rate is the number of initial
discharges with one or more PPRs within the readmission window divided
by the number of initial discharges at risk for a PPR (not globally
excluded). Provider AAA PPR rate equals 1 divided by 10 =
10%. The expected PPR rate based on the initial discharges at
risk for a PPR is the sum of the associated APRDRG by SOI normative
PPR rate times the mental health and age adjustment factor divided by
the number of initial discharges at risk for a PPR.
Example
Hospital PPR Rate
Provider

Number
of Initial Discharge With a PPR 
Number
of Initial Discharge At Risk for PPR 
Actual
PPR Rate 
Expected
PPR Rate 
AAA 
1 
10 
10.0% 
11.4% 
Risk Adjusted Value
It is not meaningful to compare expected values across
hospitals. Thus, if one hospital has a higher expected value than
another hospital, no conclusion can be made regarding the relative
performance of the two hospitals. In order to directly compare the
performance of two hospitals a risk adjusted value can be
computed. In other words, the expected value is relative to
the hospital’s actual value while the risk adjusted value is
relative to actual value in the reference database. Thus the risk
adjusted value can be compared across hospitals. The risk
adjusted value is computed as follows:
Hospital Actual PPR Rate
Risk Adjusted PPR Rate =
 X Reference Actual
PPR Rate
Hospital Expected PPR Rate
The reference actual PPR rate is the overall PPR rate
for the hospitals being compared. If analysis is performed
for a subset of cases, say cardiac surgical APRDRGs, then the overall
PPR rate for all cardiac surgical APRDRGs would be the reference
actual PPR rate from which a hospitals actual to expected PPR rate for
cardiac surgical APRDRGs would be adjusted.
Statistical significance
The statistical techniques calculate the probability
that an observed difference in performance between the provider and the
norm is due to natural variation. A difference in performance between
provider and norm is considered “significant” if
the probability that a difference is due to natural variation is small.
A difference is considered significant at the 0.05 level if the
probability that the observed difference is due to natural variation is
five percent or less (i.e., less than one chance in twenty).
Three interrelated factors determine whether a
difference in performance is significant: the number of observations,
the magnitude of the observed difference in performance, and the
variability in performance of the hospital and of the norm. A small
number of patients, a small observed difference in performance, or high
variability within either the provider or the norm (i.e., high standard
deviation) increase the probability that the observed difference is due
to chance and does not represent a true difference. Conversely, a large
number of patients, a large observed difference between provider and
norm, or low variability within both hospital and norm make it more
likely that the difference was not due to chance and does represent a
true difference.
Further, an observed difference of the same magnitude
may be significant in one comparison and not in another. The conclusion
that a difference is significant indicates that the hospital and the
norm have had true difference in performance.
There are several possible reasons why a difference may
not be significant. There may be no true difference, and thus, no
significant difference in performance is found. Alternatively, there
may be too few observations or too much variability, or both, so that
even a true difference cannot be detected. Thus, a difference which is
not significant does not necessarily mean that there is no true
difference in performance. It may simply mean that there were too few
patients or too much variability to conclude that the observed
difference was not due to chance.
The comparison of a provider’s performance to
a norm requires the use of several distinct statistical methods.
Outcome variables such as PPR rates are binary variables that indicate
the occurrence or nonoccurrence of an event such as a readmission
following an initial discharge. Comparisons can be performed for data
from a single APRDRG category and subclass, or they can be performed
for data pooled across multiple APRDRG categories and subclasses.
Test of Significance
For binary data such as readmission, a test of
significance of the difference between the actual and expected values
can be performed by comparing readmission rates separately within each
APRDRG category and subclass and then pooled across APRDRG categories
and subclasses. The calculation of statistical significance for PPRs
uses the CochranMantelHaenszel test (CMH) to calculate statistical
significance for PPRs across APRDRG categories and severity of illness
levels.
To test for statistical significance, it is assumed that
the APRDRG category and severity of illness level for each initial
discharge is known, as well as whether or not a PPR occurred within the
window following the initial discharge. The tests of significance are
to be calculated with only initial discharges at risk for
PPRs. In computing the test of significance, the normative
statistic should take into account the adjustment for age over 85 and
the presence of a major mental health problem as a comorbid condition
based on hospital’s cases.
To calculate a CMH statistic, start with the 2 * 2
matrix used for the Chi Square test. The CMH statistic uses the data
from one corner of the matrix and the marginals. It does not matter
which corner; all will produce the same results. To simplify matters,
we will use the upper left hand corner.
Calculate the expected value and variance of each cell.
Let:
j = APRDRG category and severity of illness level
E = Expected number of initial discharges with PPRs
C = Number of initial discharges with PPRs for a hospital
D = Number of initial discharges at risk for PPR for a hospital
F = Number of initial discharges with PPRs in norm
G = Number of initial discharges at risk for PPR in norm
A(m,a) = Adjustment factor for mental health status m and age category a
N(m,a) = Number of patients with mental health status m and age
category a in hospital
J = Average adjustment factor for mental health status m and age
category a in hospital
J = ∑ (N(m,a)A(m,a))/ ∑ N(m,a)
^{m,a
m,a}
The expected value is calculated as follows:
_{
}
The variance is calculated as follows:
_{
}
After, the expected value and variance are calculated,
calculate the CMH statistic as follows:
_{
}
As the CMH statistic has a chi square distribution with
1 degree of freedom the following significance levels can be used:
Significance
Level 
Х^{2}

.1 
2.7055

.05 
3.8415

.01 
6.6349

For the purposes of reporting statistical significance a
significance level of .05, Х^{2} =>
3.8415, was used. In addition, statistical significance will not be
calculated if the overall number of initial discharges at risk for PPRs
is less than forty or if the number of observed or expected initial
discharges with PPRs is less than five for a provider. Top of Page
Hospital Inpatient Medical Conditions and Procedures  Adults
Bones and Joints
Back Problems
Back Problems –
APRDRG code 347
Disc Surgery
Disc Surgery – APRDRG
code 310
Femur Fracture Surgical Repair
Femur Fracture Surgical Repair
– APRDRG code 308
Fracture of Pelvis or Dislocation of Hip
Fracture of Pelvis or
Dislocation of Hip – APRDRG code 341
Hip Replacement (total and partial)
Hip Replacement  APR DRG code
301
Knee
Replacement (total and partial)
Knee Replacement –
APRDRG code 302
Leg
Amputation
Leg Amputation – APR
DRG code 305
Shoulder,
Upperarm and Forearm Procedures
Shoulder, Upperarm and Forearm
Procedures – APR DRG code 315
Spinal
Fusion
Spinal Fusion –
APRDRG codes 303, 304 and 321
Tibia/Fibula
Fracture Repair
Tibia/Fibula Fracture Repair
– APR DRG code 313
Top of Page
Brain and Nervous System
Craniotomy
(brain surgery)
Craniotomy (brain surgery)
– APRDRG codes 20 and 21
Stroke
Stroke – APRDRG codes
44 and 45
Transient
Cerebral Ischemia
Transient Cerebral Ischemia
– APRDRG code 47 Top
of Page
Cancer
Acute
Leukemia
Acute Leukemia –
APRDRG code 690
Bone
Marrow Transplant
Bone Marrow Transplant
– APRDRG code 3
Brain
Cancer
Brain Cancer – APRDRG
code 41
Chemotherapy
Chemotherapy – APRDRG
code 693
Digestive
System Cancer
Digestive System Cancer
– APRDRG code 240
Female
Reproductive Cancer
Female Reproductive Cancer
– APRDRG code 530
Kidney
/ Ureter Removal
Kidney / Ureter Removal
– APRDRG code 442
Leukemia
/ Lymphoma, Non  Surgical
Leukemia / Lymphoma, Non 
Surgical – APRDRG codes 691 and 694
Leukemia
/ Lymphoma, Surgical
Leukemia / Lymphoma, Surgical
– APRDRG code 681
Liver/Pancreatic
Cancer
Liver Cancer – APRDRG
code 281
Lung
Cancer
Lung Cancer – APRDRG
code 136
Mastectomy
Mastectomy – APRDRG
code 362 Top of Page
Diabetes/Endocrinology/Metabolism
Diabetes
Diabetes – APRDRG
code 420
Top of Page
General Medical Information
Acute
Pancreatitis
Acute Pancreatitis –
APRDRG code 282
Cellulitis
Cellulitis – APRDRG
code 383
Convulsions
(Seizures)
Convulsions (Seizures)
– APRDRG code 53
Diverticulosis
/ Diverticulitis
Diverticulosis / Diverticulitis
– APRDRG code 244
Gastrointestinal
Hemorrhage
Gastrointestinal Hemorrhage
– APRDRG codes 241, 242 and 253
Hypovolemia
(Low Blood Volume)
Hypovolemia (Low Blood Volume)
– APRDRG code 422
Inflammatory
Bowel Disease
Inflammatory Bowel Disease
– APRDRG code 245
Migraine
and Other Headaches
Migraine and Other Headaches
– APRDRG code 54
NonBacterial
Gastroenteritis, Nausea and Vomiting
NonBacterial Gastroenteritis,
Nausea and Vomiting – APRDRG code 249
Renal
Failure
Renal Failure –
APRDRG code 460
Septicemia
(blood poisoning)
Septicemia (blood poisoning)
– APRDRG codes 720 and 724
Sickle
Cell Disease
Sickle Cell Disease –
APRDRG code 662
Syncope
(fainting)
Syncope (fainting) –
APRDRG code 204
Urinary
Stones
Urinary Stones –
APRDRG code 465
Urinary
Tract Infection
Urinary Tract Infection
– APRDRG code 463 Top of Page
Heart and Circulatory System
Angina
Pectoris and Coronary Atherosclerosis
Angina Pectoris and Coronary
Atherosclerosis – APRDRG codes 198
Angioplasty
Angioplasty – APRDRG
codes 174 and 175
Cardiac
Catheterization
Cardiac Catheterization
– APRDRG codes 191 and 192
Cardiac
Defibrillator and Heart Assist Anomaly
Cardiac Defibrillator and Heart
Assist Anomaly – APRDRG code 161
Cardiac
Pacemaker Implant
Cardiac Pacemaker Implant
– APRDRG code 171
Cardiac
Valve Procedures without Cardiac Catheterization
Cardiac Valve Procedures without
Cardiac Catheterization – APRDRG code 163
Chest
Pain
Chest Pain – APRDRG
code 203
Coronary
Bypass Surgery
Coronary Bypass Surgery
– APRDRG codes 165 and 166
Heart
Attack
Heart Attack – APRDRG
code 190
Heart
Failure
Heart Failure –
APRDRG code 194
High
Blood Pressure
High Blood Pressure –
APRDRG code 199
Irregular
Heartbeat
Irregular Heartbeat –
APRDRG code 201
Major
Thoracic and Abdominal Vascular Procedures
Major Thoracic and Abdominal
Vascular Procedures – APRDRG code 169
Peripheral
Vascular Disease (PVD)
Peripheral Vascular Disease
(PVD) – APRDRG code 197
Pulmonary
Edema and Respiratory Failure
Pulmonary Edema and Respiratory
Failure – APRDRG code 133 Top of Page
Lungs
Asthma
Asthma – APRDRG code
141
Chronic
Obstructive Pulmonary Disease, COPD (pulmonary disease)
COPD (pulmonary disease)
– APRDRG code 140
Lung
and Chest Procedures
Lung and Chest Procedures
– APRDRG codes 120 and 121
Pneumonia
Pneumonia – APRDRG
code 139
Pneumonitis,
Aspiration
Pneumonitis, Aspiration
– APRDRG code 137
Top of Page
Surgery
Appendectomy
Appendectomy – APRDRG
code 225
Arteriovenostomy
(renal dialysis)
Arteriovenostomy (renal
dialysis) – APRDRG code 444
Gall
Bladder Removal
Gall Bladder Removal –
APRDRG 262
Heart
and/or Lung Transplant
Heart and/or Lung Transplant
– APRDRG code 2
Hernia
Repair
Hernia Repair, Other –
APRDRG code 227
Inguinal,
Femoral and Umbilical Hernia Procedures
Inguinal, Femoral and Umbilical
Hernia Procedures – APRDRG code 228
Kidney/Pancreas
Transplant
Kidney/Pancreas Transplant
– APRDRG codes 6 and 440
Laparoscopic
Gall Bladder Removal
Laparoscopic Gall Bladder
Removal – APRDRG code 263
Liver
Transplant
Liver Transplant –
APRDRG code 1
Major
Small and Large Bowel Procedures
Major Small and Large Bowel
Procedures – APRDRG code 221
Major
Stomach, Esophageal and Duodenal Procedures
Major Stomach, Esophageal and
Duodenal Procedures – APRDRG code 220
Minor
Small and Large Bowel Procedures
Minor Small and Large Bowel
Procedures – APRDRG code 223
Obesity
Procedures
Obesity Procedures –
APRDRG code 403
Peritoneal
Adhesiolysis
Peritoneal Adhesiolysis 
APRDRG code 224
Radical
Prostatectomy
Radical Prostatectomy
– APRDRG code 480
Thyroid,
Parathyroid and Thyroglossal Procedures
Thyroid, Parathyroid and
Thyroglossal Procedures – APRDRG code 404
Transurethral
Prostatectomy
Transurethral Prostatectomy
– APRDRG code 482
Urethral
and Transurethral Procedures
Urethral and Transurethral
Procedures – APRDRG code 446
Top of Page
Women's Health
Hysterectomies
and Other Uterine and Adnexa Procedures
Hysterectomies and Other Uterine
and Adnexa Procedures – APRDRG codes 511, 512, 513 and
519 Top of Page
Hospital Inpatient Medical
Conditions and Procedures  Deliveries and Newborns
Baby
with Complications
Baby with Complications
– APRDRG codes 583, 588, 589, 591, 593, 602, 603, 607, 608,
609, 611, 612, 613, 614, 621, 622, 623, 625, 626, 630, 631, 633, 634,
636, 639, 640 (APRDRG 640 is limited to Severity Levels 2, 3 and 4)
Cesarean
Section Delivery
Cesarean Section Delivery
– APRDRG code 540  The data for cesarean deliveries include
all ages.
Normal
Baby
Normal Baby – APRDRG
code 640 (limited to Severity Level 1)
Vaginal
Delivery
Vaginal Delivery –
APRDRG code 560  The data for vaginal deliveries include all ages. Top of Page
Hospital Inpatient Medical
Conditions and Procedures  Pediatrics
Appendectomy
– Ages 117 years
Appendectomy – APRDRG
code 225 (limited to Severity Level 1, minor) – Ages 117
years
Asthma
– Ages 217 years
Asthma –Inclusions:
ICD9CM principal diagnosis codes of asthma, 49300, 49301, 49302,
49310, 49311, 49312, 49320, 49321, 49322, 49381, 49382, 49390, 49391,
and 49392. Exclusions: Excludes
those patients with a diagnosis code for cystic fibrosis and anomalies
of the respiratory system. Excludes transfers from other
institutions. Excludes cases ages 01. Excludes cases in MDC
14 (obstetrics). Please refer to PDI 14 (AHRQ Version 4.2) at
www.qualityindicators.ahrq.gov
for further information regarding methodology.
Brain
Surgery – Ages 017 years
Brain Surgery –
APRDRG codes 20, 21, and 22 – Ages 017 (excluding birth
hospitalizations and newborn transfers less than or equal to 28 days
old).
Bronchiolitis
and RSV Pneumonia – Ages 04 years
Bronchiolitis and RSV Pneumonia
– APRDRG code 138 – Ages 04 (excluding birth
hospitalizations and newborn transfers less than or equal to 28 days
old).
Cancer
Care – Ages 017 years
Cancer Care – APRDRG
codes 680, 681, 690, 691, 692, 693, 694, and 41 – Ages 017
(excluding birth hospitalizations and newborn transfers less than or
equal to 28 days old).
Cellulitis
– Ages 017 years
Cellulitis – APRDRG
code 383 (excluding birth hospitalizations and newborn transfers less
than or equal to 28 days old).
Convulsions
(Seizures) – Ages 04 years and 517 years
Convulsions (Seizures)
– APRDRG code 53 – Ages 04 (excluding birth
hospitalizations and newborn transfers less than or equal to 28 days
old) and ages 517.
Diabetes
– Ages 617 years
Diabetes – Inclusions:
All nonmaternal discharges ages 6 to 17 years with ICD9CM principal
diagnosis codes for shortterm complications (ketoacidosis,
hyperosmolarity, coma) including 25010, 25011, 25012, 25013, 25020,
25021, 25022, 25023, 25030, 25031, 25032, and 25033. Exclusions:
Excludes transfers from other institutions. Excludes cases in MDC 14
(obstetrics). Please refer to PDI 15 (AHRQ Version 4.2) at www.qualityindicators.ahrq.gov
for further information regarding methodology.
Fever
and Infectious Illness – Ages 017 years
Fever and Infectious Illness
– APRDRG codes 722, 723, and 113 – Ages 017
(excluding birth hospitalizations and newborn transfers less than or
equal to 28 days old).
Gastroenteritis
– Ages 3 months – 4 years and 517 years
Gastroenteritis – Inclusions:
All nonmaternal discharges ages 1 year4 years and 517 years with
ICD9CM principal diagnosis code for gastroenteritis or with a
secondary diagnosis code of gastroenteritis and a principal diagnosis
code of dehydration. ICD9CM gastroenteritis diagnosis codes 00861,
00862, 00863, 00864, 00865, 00866, 00867, 00869, 0088, 0090, 0091,
0092, 0093, and 5589. ICD9CM dehydration diagnosis codes 27650,
27651, 27652, and 2765. Exclusions: Excludes
transfers from other institutions. Exclude those with a diagnosis code
of gastrointestinal abnormalities or bacterial gastroenteritis.
Excludes ages less than 1 year (or neonates if age in days is missing).
Excludes cases in MDC 14 (obstetrics). Please refer to PDI 16 (AHRQ
Version 4.2) at www.qualityindicators.ahrq.gov
for further information regarding methodology.
Pneumonia,
Other – Ages 217 years
Pneumonia, Other – APR
139. Inclusions:Includes ages 217. Exclusions:
Excludes transfers from other institutions. Exclude cases in MDC 14
(obstetrics). Excludes those patients with a diagnosis code for cystic
fibrosis and anomalies of the respiratory system. Please refer to PDI
14 (AHRQ Version 4.2) at www.qualityindicators.ahrq.gov
for further information regarding methodology.
Sickle
Cell Disease – Ages 117 years
Sickle Cell Disease –
APRDRG code 662 – Ages 117.
Spinal
Fusion – Ages 517 years
Spinal Fusion –
APRDRG codes 303, 304, and 321 – Ages 517 years.
Urinary
Tract Infections – Ages 3 months to 17 years
Urinary Tract Infections
– Inclusions: All nonmaternal discharges
ages 1 year to 17 years with ICD9CM urinary tract principal diagnosis
codes 59010, 59011, 5902, 5903, 59080, 59081, 5909, 5950, 5959, 5990.
Exclusions: : Excludes transfers from
other institutions. Exclude those patients with a diagnosis code of
kidney/urinary tract disorder and with a diagnosis code of high or
intermediaterisk immunocompromised state. Excludes ages less than 1
year (or neonates if age in days is missing). Excludes cases in MDC 14
(obstetrics). Please refer to PDI 18 (AHRQ Version 4.2) at www.qualityindicators.ahrq.gov
for a list of the kidney/urinary disorder diagnosis codes and refer to
Appendixes C and D for ICD9CM Codes for Immunocompromised States and
ICD9CM Codes for Intermediaterisk Immunocompromised States and more
detailed information regarding methodology.
Viral
Meningitis – Ages 017 years
Viral Meningitis –
APRDRG code 51 – Ages 017 years (excluding birth
hospitalizations and newborn transfers less than or equal to 28 days
old).
Top of Page
Ambulatory (Outpatient) Surgery
Centers
Enhanced Ambulatory Patient Groups (EAPGs)
– Explanation of Designation as Levels IIV
EAPGs simplify ambulatory visits for analysis and
reporting. This is achieved by identifying key diagnoses and
procedures, both diagnostic and therapeutic, performed during an
ambulatory visit. Once identified, these diagnoses and procedures are
used to classify outpatient visits into categories, called EAPGs, that
are both clinically and financial meaningful.
Once the EAPGs are assigned, a second step is taken that
assigns a level of complexity to each respective EAPG. Levels I through
IV may be assigned to each EAPG. The complexity of an EAPG is defined
by the following criteria: clinical similarity within an EAPG, the type
(e.g. incision vs excision) of procedures in a particular EAPG, the
amount of resources needed for the procedures in an EAPG, and the
likelihood that other ancillaries (e.g. diagnostic vs therapeutic
procedures involving different types of surgical and other types of
surgical pathology) will be performed for the procedure in that EAPG.
Levels of complexity are characterized
as follows:
Level I 
– 
Short treatment time in
the operating room. Few laboratory tests or radiology procedures
ordered. Few expensive disposable devices used, if any. 
Level II 
– 
Laboratory tests and
radiology procedures typically ordered as part of procedure. Disposable
devices may consume significant resources. Increased length of time in
the operating room. 
Level III 
– 
Laboratory tests and
radiology procedures ordered as part of a procedure. Disposable devices
consume significant resources. Longer stay in the operating room than
levels I and II. 
Level IV 
– 
Procedure of major
complexity. Treatment and resources used are extensive. Thus, Level IV
EAPGs are frequently performed in an inpatient setting, not in an
outpatient setting. 
Top of Page
Ambulatory (Outpatient) Surgery
Centers Procedures/Surgeries  Adults
Bones and Joints
Arthroscopy,
Level I – EAPG 37
Arthroscopy,
Level II – EAPG 38
Bunion
Procedures – EAPG 45
Open or
Percutaneous Treatment of Fractures –
EAPG 43
Digestive System
Colonoscopy,
Therapeutic – EAPG 137
Endoscopy of
the Lower Airway – EAPG 64
Endoscopy of
the Upper Airway, Level I – EAPG 62
Endoscopy of
the Upper Airway, Level II – EAPG 63
Hernia
Repair, Level I – EAPG 139
Hernia
Repair, Level II – EAPG 140
Lower
Gastrointestinal Endoscopy, Diagnostic
– EAPG 136
Upper
Gastrointestinal (GI) Endoscopy or Intubation, Diagnostic
– EAPG 134
Upper
Gastrointestinal (GI) Endoscopy or Intubation, Therapeutic
– EAPG 135
Eyes
Cataract
Procedures – EAPG 233
Laser Eye
Procedures – EAPG 232
General Surgery
Facial and
Ear, Nose and Throat Procedures, Level I
– EAPG 252
Facial and
Ear, Nose and Throat Procedures, Level II
– EAPG 253
Facial and
Ear, Nose and Throat Procedures, Level III
– EAPG 254
Facial and
Ear, Nose and Throat Procedures, Level IV
– EAPG 255
Tonsil and
Adenoid Procedures – EAPG 256
Heart and Circulatory System
Cardiac
Catheterization, Diagnostic – EAPG 84
Pacemaker
Insertion and Replacement – EAPG 86
Kidneys and Urologic System
Bladder and
Kidney Procedures, Level I – EAPG 163
Bladder and
Kidney Procedures, Level II – EAPG 164
Bladder and
Kidney Procedures, Level III – EAPG 165
Extracorporeal
Shock Wave Lithotripsy – EAPG 160
Skin
Excision and
Biopsy of Skin and Soft Tissue, Level I
– EAPG 9
Excision and
Biopsy of Skin and Soft Tissue, Level II
– EAPG 10
Excision and
Biopsy of Skin and Soft Tissue, Level III
– EAPG 11
Skin
Debridement and Destruction, Level I –
EAPG 6
Skin
Debridement and Destruction, Level II
– EAPG 7
Skin
Debridement and Destruction, Level III
– EAPG 8
Women’s Health
Breast
Procedure, Level I – EAPG 20
Breast
Procedure, Level II – EAPG 21
Breast
Procedure, Level III – EAPG 22
Hysteroscopy
– EAPG 200 Top of Page
Ambulatory (Outpatient) Surgery
Centers Procedures/Surgeries  Pediatrics
Bones and Joints
Arthroscopy,
Level I – EAPG 37
Arthroscopy,
Level II – EAPG 38
Open or
Percutaneous Treatment of Fractures –
EAPG 43
Digestive System
Endoscopy of
the Lower Airway – EAPG 64
Endoscopy of
the Upper Airway, Level I – EAPG 62
Endoscopy of
the Upper Airway, Level II – EAPG 63
Hernia
Repair, Level I – EAPG 139
Hernia
Repair, Level II – EAPG 140
Lower
Gastrointestinal (GI) Endoscopy, Diagnostic
– EAPG 136
Upper
Gastrointestinal (GI) Endoscopy or Intubation, Diagnostic
– EAPG 134
Upper
Gastrointestinal (GI) Endoscopy or Intubation, Therapeutic
– EAPG 135
Eyes
Strabismus
(Repair of CrossEyed) and Muscle Eye Procedures
– EAPG 239
General Surgery
Circumcision
– EAPG 181
Facial and
Ear, Nose and Throat Procedures, Level I
– EAPG 252
Facial and
Ear, Nose and Throat Procedures, Level II
– EAPG 253
Facial and
Ear, Nose and Throat Procedures, Level III
– EAPG 254
Facial and
Ear, Nose and Throat Procedures, Level IV
– EAPG 255
Tonsil and
Adenoid Procedures – EAPG 256
Top of Page
Physician Volume
The inpatient physician volume data includes discharges with
ICD10CM codes in the principal procedure field for those ages 18 and older
for Total Hip Replacement and Total Knee Replacement. Physicians who performed less than 10 procedures
statewide were suppressed from the data and will not be shown on the website. Due to the implementation
of the ICD10CM codes, the following physician volume measures were not updated but will be included on
the website in the near future: Percutaneous Transluminal Coronary Angioplasty (PTCA), Coronary Artery
Bypass Graft (CABG) and Spinal Fusion.
IMPORTANT: This methodology varies from the Compare Hospitals facility level information
thus the totals are not comparable.
