TABLE 4.
Professional Fee Ratio Estimates by Top 100 DRG, Commercially Insured Inpatient Admissions, 2012
| DRG | Description | n | Rank by Sample Size |
PFR (95% CI) |
|---|---|---|---|---|
| 25 | CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC | 5950 | 77 | 1.287 (1.277, 1.298) |
| 64 | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC | 6407 | 73 | 1.165 (1.160, 1.169) |
| 65 | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC | 7873 | 60 | 1.153 (1.151, 1.156) |
| 69 | TRANSIENT ISCHEMIA | 6736 | 71 | 1.178 (1.174, 1.182) |
| 101 | SEIZURES W/O MCC | 14,254 | 30 | 1.202 (1.198, 1.206) |
| 103 | HEADACHES W/O MCC | 9212 | 46 | 1.147 (1.144, 1.150) |
| 153 | OTITIS MEDIA & URI W/O MCC | 7714 | 62 | 1.125 (1.122, 1.128) |
| 164 | MAJOR CHEST PROCEDURES W CC | 5523 | 82 | 1.273 (1.267, 1.279) |
| 176 | PULMONARY EMBOLISM W/O MCC | 8916 | 49 | 1.115 (1.113, 1.117) |
| 189 | PULMONARY EDEMA & RESPIRATORY FAILURE | 6316 | 75 | 1.116 (1.114, 1.118) |
| 190 | CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC | 7428 | 66 | 1.122 (1.120, 1.125) |
| 191 | CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC | 5665 | 79 | 1.119 (1.117, 1.122) |
| 193 | SIMPLE PNEUMONIA & PLEURISY W MCC | 8304 | 56 | 1.133 (1.130, 1.135) |
| 194 | SIMPLE PNEUMONIA & PLEURISY W CC | 17,823 | 22 | 1.115 (1.113, 1.117) |
| 195 | SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC | 12,173 | 35 | 1.104 (1.102, 1.105) |
| 202 | BRONCHITIS & ASTHMA W CC/MCC | 15,024 | 28 | 1.129 (1.127, 1.132) |
| 203 | BRONCHITIS & ASTHMA W/O CC/MCC | 16,665 | 23 | 1.106 (1.104, 1.108) |
| 234 | CORONARY BYPASS W CARDIAC CATH W/O MCC | 5632 | 80 | 1.212 (1.207, 1.218) |
| 247 | PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC | 16,016 | 26 | 1.113 (1.110, 1.116) |
| 249 | PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC | 8359 | 54 | 1.127 (1.124, 1.131) |
| 251 | PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC | 6829 | 70 | 1.173 (1.165, 1.181) |
| 282 | ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC | 4802 | 97 | 1.146 (1.141, 1.150) |
| 287 | CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC | 18,175 | 20 | 1.142 (1.139, 1.145) |
| 292 | HEART FAILURE & SHOCK W CC | 5983 | 76 | 1.137 (1.134, 1.140) |
| 300 | PERIPHERAL VASCULAR DISORDERS W CC | 4742 | 98 | 1.130 (1.127, 1.134) |
| 305 | HYPERTENSION W/O MCC | 4715 | 99 | 1.142 (1.139, 1.146) |
| 309 | CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC | 7949 | 59 | 1.158 (1.154, 1.162) |
| 310 | CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC | 15,066 | 27 | 1.153 (1.150, 1.155) |
| 312 | SYNCOPE & COLLAPSE | 9035 | 48 | 1.166 (1.162, 1.170) |
| 313 | CHEST PAIN | 18,180 | 19 | 1.152 (1.149, 1.154) |
| 329 | MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC | 8245 | 57 | 1.192 (1.188, 1.197) |
| 330 | MAJOR SMALL & LARGE BOWEL PROCEDURES W CC | 18,355 | 18 | 1.228 (1.225, 1.231) |
| 331 | MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC | 7789 | 61 | 1.247 (1.242, 1.253) |
| 343 | APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC | 18,361 | 17 | 1.286 (1.279, 1.293) |
| 372 | MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC | 4696 | 100 | 1.125 (1.122, 1.128) |
| 378 | G.I. HEMORRHAGE W CC | 8829 | 50 | 1.189 (1.186, 1.193) |
| 386 | INFLAMMATORY BOWEL DISEASE W CC | 5867 | 78 | 1.154 (1.151, 1.157) |
| 389 | G.I. OBSTRUCTION W CC | 6879 | 69 | 1.135 (1.132, 1.138) |
| 390 | G.I. OBSTRUCTION W/O CC/MCC | 7623 | 63 | 1.127 (1.124, 1.130) |
| 391 | ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC | 9424 | 43 | 1.164 (1.161, 1.167) |
| 392 | ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC | 57,167 | 8 | 1.146 (1.145, 1.148) |
| 394 | OTHER DIGESTIVE SYSTEM DIAGNOSES W CC | 7366 | 67 | 1.150 (1.146, 1.153) |
| 417 | LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC | 4815 | 96 | 1.250 (1.243, 1.258) |
| 418 | LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC | 14,253 | 31 | 1.296 (1.289, 1.303) |
| 419 | LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC | 9342 | 44 | 1.265 (1.257, 1.272) |
| 439 | DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC | 8397 | 53 | 1.137 (1.134, 1.140) |
| 440 | DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC | 8155 | 58 | 1.129 (1.127, 1.132) |
| 460 | SPINAL FUSION EXCEPT CERVICAL W/O MCC | 22,662 | 14 | 1.311 (1.299, 1.324) |
| 470 | MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC | 85,579 | 5 | 1.196 (1.194, 1.197) |
| 472 | CERVICAL SPINAL FUSION W CC | 6383 | 74 | 1.483 (1.464, 1.502) |
| 473 | CERVICAL SPINAL FUSION W/O CC/MCC | 13,828 | 32 | 1.499 (1.485, 1.513) |
| 490 | BACK & NECK PROC EXC SPINAL FUSION W CC/MCC OR DISC DEVICE/NEUROSTIM | 5237 | 89 | 1.378 (1.361, 1.395) |
| 491 | BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC | 11,567 | 37 | 1.442 (1.428, 1.456) |
| 493 | LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W CC | 5334 | 88 | 1.220 (1.213, 1.228) |
| 494 | LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W/O CC/MCC | 9187 | 47 | 1.215 (1.209, 1.220) |
| 552 | MEDICAL BACK PROBLEMS W/O MCC | 7562 | 65 | 1.134 (1.129, 1.138) |
| 581 | OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC | 5393 | 84 | 1.525 (1.505, 1.546) |
| 603 | CELLULITIS W/O MCC | 28,612 | 12 | 1.125 (1.124, 1.127) |
| 620 | O.R. PROCEDURES FOR OBESITY W CC | 4928 | 92 | 1.310 (1.301, 1.320) |
| 621 | O.R. PROCEDURES FOR OBESITY W/O CC/MCC | 21,179 | 15 | 1.322 (1.314, 1.329) |
| 627 | THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC | 5046 | 91 | 1.341 (1.332, 1.351) |
| 638 | DIABETES W CC | 9257 | 45 | 1.130 (1.128, 1.133) |
| 639 | DIABETES W/O CC/MCC | 8471 | 52 | 1.122 (1.120, 1.124) |
| 641 | MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC | 16,596 | 24 | 1.124 (1.122, 1.126) |
| 669 | TRANSURETHRAL PROCEDURES W CC | 4895 | 93 | 1.234 (1.226, 1.242) |
| 682 | RENAL FAILURE W MCC | 5590 | 81 | 1.147 (1.143, 1.152) |
| 683 | RENAL FAILURE W CC | 8583 | 51 | 1.140 (1.137, 1.142) |
| 690 | KIDNEY & URINARY TRACT INFECTIONS W/O MCC | 14,377 | 29 | 1.121 (1.119, 1.123) |
| 694 | URINARY STONES W/O ESW LITHOTRIPSY W/O MCC | 8339 | 55 | 1.164 (1.160, 1.168) |
| 708 | MAJOR MALE PELVIC PROCEDURES W/O CC/MCC | 7613 | 64 | 1.474 (1.462, 1.485) |
| 742 | UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC | 12,556 | 34 | 1.292 (1.286, 1.297) |
| 743 | UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC | 43,753 | 10 | 1.327 (1.324, 1.330) |
| 765 | CESAREAN SECTION W CC/MCC | 71,241 | 6 | 1.465 (1.463, 1.467) |
| 766 | CESAREAN SECTION W/O CC/MCC | 102,725 | 3 | 1.521 (1.520, 1.523) |
| 767 | VAGINAL DELIVERY W STERILIZATION &/OR D&C | 6588 | 72 | 1.598 (1.589, 1.607) |
| 774 | VAGINAL DELIVERY W COMPLICATING DIAGNOSES | 42,034 | 11 | 1.580 (1.576, 1.583) |
| 775 | VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES | 271,937 | 1 | 1.644 (1.642, 1.645) |
| 776 | POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE | 5388 | 85 | 1.136 (1.131, 1.141) |
| 778 | THREATENED ABORTION | 5519 | 83 | 1.099 (1.093, 1.106) |
| 781 | OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS | 16,031 | 25 | 1.135 (1.132, 1.139) |
| 782 | OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS | 4852 | 94 | 1.280 (1.269, 1.291) |
| 790 | EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE | 11,521 | 38 | 1.241 (1.235, 1.246) |
| 791 | PREMATURITY W MAJOR PROBLEMS | 7324 | 68 | 1.223 (1.217, 1.229) |
| 792 | PREMATURITY W/O MAJOR PROBLEMS | 11,766 | 36 | 1.191 (1.187, 1.195) |
| 793 | FULL TERM NEONATE W MAJOR PROBLEMS | 26,979 | 13 | 1.288 (1.283, 1.292) |
| 794 | NEONATE W OTHER SIGNIFICANT PROBLEMS | 58,504 | 7 | 1.236 (1.233, 1.238) |
| 795 | NORMAL NEWBORN | 155,892 | 2 | 1.214 (1.213, 1.215) |
| 809 | MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC | 4835 | 95 | 1.090 (1.088, 1.092) |
| 812 | RED BLOOD CELL DISORDERS W/O MCC | 10,784 | 41 | 1.132 (1.130, 1.135) |
| 847 | CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC | 11,128 | 39 | 1.066 (1.065, 1.068) |
| 853 | INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC | 5377 | 86 | 1.159 (1.154, 1.165) |
| 864 | FEVER | 5375 | 87 | 1.125 (1.122, 1.129) |
| 871 | SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC | 18,402 | 16 | 1.130 (1.128, 1.132) |
| 872 | SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W/O MCC | 11,064 | 40 | 1.116 (1.114, 1.118) |
| 881 | DEPRESSIVE NEUROSES | 12,682 | 33 | 1.135 (1.133, 1.138) |
| 885 | PSYCHOSES | 100,491 | 4 | 1.129 (1.129, 1.130) |
| 897 | ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC | 51,095 | 9 | 1.084 (1.083, 1.085) |
| 917 | POISONING & TOXIC EFFECTS OF DRUGS W MCC | 5178 | 90 | 1.135 (1.131, 1.139) |
| 918 | POISONING & TOXIC EFFECTS OF DRUGS W/O MCC | 9536 | 42 | 1.132 (1.129, 1.135) |
| 945 | REHABILITATION W CC/MCC | 17,930 | 21 | 1.115 (1.113, 1.117) |
Estimates based on data from Truven Health MarketScan data, 2012, Inpatient Admissions files.
Data are average predicted values from ordinary least squares multivariable linear regression models with robust SEs (StataCorp, 2013), adjusted for all selected patient and health service characteristics demonstrated in Table 1.
MDC and DRG descriptions from Centers for Medicare and Medicaid Services.25 Historic descriptions from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareFeeforSvcPartsAB/MEDPAR.html.
Professional fee ratio estimates for other years, clinical classifications, and Medicaid patients reported in SDC Table 3, Supplemental Digital Content 3, http://links.lww.com/MLR/B4.
CI indicates confidence interval; DRG, Diagnostic Related Group; MDC, Major Diagnostic Category; PFR, professional fee ratio.