Payment for Newborns

Neonate claims that are grouped into Major Diagnostic Category (MDC) 15 “Newborns and other Neonates with Conditions Originating in the Perinatal Period” (DRGs 789-795) are further grouped using Oklahoma specific enhanced newborn logic. The enhanced newborn logic creates 20 new groupings, DRGs N01 – N80, from the seven in MDC 15. The groupings are hierarchical based on birth weight, discharge status, transfer status, major operating room procedure performed, and the existence of multiple, major or other problems which exist at birth. The birth weight is to be indicated through use of the neonatal ICD diagnosis code. The birth weight is to be indicated through use of a fifth digit on the neonatal ICD diagnosis code. The following rules apply to newborns:

Birth weight/Diagnosis

  1. If a neonate (normally patient age 0 - 28 days at admission) is premature, the appropriate diagnosis code associated with prematurity must be used as a principal or secondary diagnosis. These ICD diagnoses indicate disorders relating to short gestation and low birth weight; extreme prematurity; other preterm infants; and weeks of gestation.
  2. If there is more than one birth weight on the claim, the highest birth weight will be used.
  3. Use of a value of ‘0’ for birth weight will result in the claim assuming a birth weight >2499 grams

Discharge Status/Transfers

  1. A discharge will be based on patient status: Home = 01, 06, 50 Death = 20, 41, 42
  2. A transfer is determined by the source of admission, 4 or 6

Operating Room Procedures Performed

There is no higher reimbursement if circumcision or other minor surgery codes are included on the claim.

Major Surgery ICD procedure codes

Newborn Q&As

How will Neonate DRGs be calculated?

OHCA uses an enhanced set of DRGs for newborns (which expands MDC 15) and creates 20 DRGs (DRGs N01-N80) with assignment based on birth weight, discharge status, and presence of major OR procedures.

Will the neonate DRGs complication or co-morbidity codes regarding neonates be available?

No. In addition to birth weight the major drivers for the expanded neonate assignment logic are admit and discharge status and the presence of an OR procedure, excluding minor OR procedures and circumcisions.

Where do we put the code for birth weight?

There is no field for birth weight. The birth weight, if applicable to coding the claim, is to be indicated through the appropriate ICD diagnosis codes.

If claims do not come in with DRG, how is a DRG assigned?

The DRG methodology will calculate payment based on grouping the diagnosis and procedure codes listed on the claim. If a DRG is listed on the claim, it will not be used to calculate the payment.