Hospital Payment Policy
Hospital Payment Policy
Inpatient acute care hospital services are reimbursed on a prospective basis using the All Patient Refined Diagnosis Related Group (APR-DRG) system. Outpatient acute care and ambulatory surgical center (ASC) services are reimbursed on a prospective basis using the Enhanced Ambulatory Patient Groups (EAPG) system. A small portion of hospital services provided in freestanding rehabilitation or long term hospitals, in hospitals which are licensed as HMOs, and in cancer hospitals are not subject to APR-DRG or EAPG reimbursement.
The billing guidelines for hospitals and ASCs are available on the Billing webpage.
Under the APR-DRG system, hospitals are reimbursed based on the principal diagnosis or condition requiring the hospital admission. The APR-DRG system is designed to classify patients into groups that are clinically coherent with respect to the amount of resources required to treat a patient with a specific diagnosis. Applicable additional payments are added for capital, medical education, and outliers.
Ohio chose to use this system in an effort to contain costs, to permit providers to operate in a less regulated environment, and to allow sharing of savings for those providers who identify ways to provide quality services more efficiently and economically. Just as hospitals do not get more than their fixed payment if the APR-DRG amount is less than charges, their APR-DRG payment rate is not lowered to match the billed charge amount.
Under the EAPG system, outpatient hospital and ASC facility claims are reimbursed based on the principal diagnosis and procedure codes submitted for a date of service. The EAPG system is designed to classify services into groups that utilize similar resources and have similar costs. The EAPG system also applies discounting factors which could cause a detail line to consolidate, package, or discount.
With the implementation of the EAPG system, Ohio moves away from prospectively determined fee schedule rates. The EAPG reimbursement methodology enables the department to cover new procedure codes more efficiently as the EAPG system maps the new procedure codes to a specific EAPG, which already have established relative weights.
Inpatient Relative Weights
Ohio has implemented 3M’s All Patient Refined Diagnosis Related Groups (APR-DRG). It is the Department’s intent to stay current with grouping software releases. Regardless of the APR-DRG Grouper Version in use, hospitals are expected to always bill using the diagnosis and procedure codes that were in effect as of the date of discharge.
- APR-DRG Version 39 – Claims discharged on or after October 1, 2021
- APR-DRG Version 38 – Claims discharged on or after October 1, 2020
- APR-DRG Version 37.1 – Claims discharged on or after April 1, 2020
- APR-DRG Version 37 – Claims discharged on or after October 1, 2019
- APR-DRG Version 36 – Claims discharged on or after October 1, 2018
- APR-DRG Version 35 – Claims discharged on or after October 1, 2017
- APR-DRG Version 34 - Claims discharged on or after October 1, 2016
- DRG Version 15 - Claims discharged on or before June 30, 2013
- APR-DRG Descriptions for version 39
- APR-DRG Descriptions for version 38
- APR-DRG Descriptions for version 37-37.1
- APR-DRG Descriptions for versions 35-36
- APR-DRG Descriptions for version 34
APR-DRG Relative Weight Tables
Each Relative Weight Table in the list below is effective until superseded by the next update. The most recent set of Relative Weights is at the top of the list.
- Discharges on or after 10/01/2020 (published 9/25/2020)
- Discharges on or after 04/01/2020 (published 4/30/2020)
- Discharges on or after 10/01/2019 (published 10/02/2019)
- Discharges on or after 09/01/2018 (published 8/16/2018)
- Discharges on or after 10/01/2017 (published 10/12/2017)
- Discharges on or after 07/06/2017 (published 7/17/2017)
- Discharges on or after 10/01/2016 (published 10/24/2016)
- Relative Weight Tables (published 10/04/2021)
Outpatient Relative Weights
Ohio has implemented 3M's Enhanced Ambulatory Patient Groups (EAPG) system for outpatient and ASC facility claims. Regardless of the EAPG Grouper Version in use, providers are expected to always bill using the diagnosis and procedure codes that were in effect as of the date of service.
- EAPG Version 3.9 - Outpatient Claims for services on or after August 1, 2017
- EAPG Version 3.14 - Outpatient Claims for services on or after January 2, 2020
EAPG Relative Weight Tables
- Outpatient Services on or after 04/01/2021 (published 03/05/2021)
- Outpatient Services on or after January 2, 2020 (published 05/15/2020)
- Outpatient Services between August 1, 2017 and January 1, 2020 (published 1/24/2020)
- Relative Weight Tables (published 03/05/2021)