Medi-Cal DRG 2017-18 Pricing Calculator Medi-Cal DRG Pricing Calculator for FY 2017-18 Effective for Dates of Admission Between July 1, 2017, and June 30, 2018 May 22, 2017 W17-888 This DRG Pricing Calculator is intended to enable hospitals and other interested parties to understand and predict estimated payment for inpatient stays covered by fee- for-service Medi-Cal. This version applies to stays with dates of admission on or after July 1, 2017, through June 30, 2018. Annual updates necessitate a new calculator that reflects new wage index values, hospital-specific base rates, and other changes. For stays with dates of admission prior to July 1, 2017, see the DHCS DRG webpage. In this file, the "Calculator" sheet incorporates the pricing logic for the complete array of DRG pricing options. The "DRG Table" tab shows information specific to each DRG. The "Hospital Characteristics" tab shows information specific to each hospital. The DRG Base Rate"tab provides information related to wage area and base rate determination. Effective July 1, 2017, outlier payments are to be calculated using a single cost outlier threshold with corresponding marginal cost percentage. In previous years, a two- tiered system was used to calculate payments. Under DRG payment, the Medicaid claims processing system assigns each complete inpatient stay to an All Patient Refined Diagnosis Related Group (APR-DRG) based on the diagnoses and procedures on the claim. (Note that Medi-Cal does not use Medicare DRGs, which were not designed for a Medicaid population.) Hospitals need not put the DRG on the claim and need not purchase APR-DRG software. The "Calculator" tab assumes the user knows which APR-DRG applies to a particular stay. For more information on APR-DRGs, contact 3M Health Information Systems, which developed and owns the software. This calculator is intended to be helpful to users to estimate pricing, but it cannot capture all the editing and pricing complexity of the Medicaid claims processing system. In cases of difference, the claims processing system is correct. A "Frequently Asked Questions" document is available and is essential to understanding the payment method. This DRG Pricing Calculator is also available in spreadsheet form as an interactive Excel file. Both documents are at the Medi-Cal DRG page at http://www.dhcs.ca.gov. To sign up for the DRG listserv or to ask a DRG policy question, email [email protected]. (Do not send any protected health information by email.) For questions about claims, contact the Medi-Cal Telephone Service Center at 800.541.5555. This calculator was developed by Conduent, the fiscal intermediary for Medi-Cal. It includes data obtained through the use of proprietary computer software created, owned, and licensed by the 3M Company. All copyrights in and to the 3M TM Software are owned by 3M. All rights reserved. 3M bears no responsibility for the contents of this document. Tab 1- Cover 2017-05-22
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W17-888 CA Medi-Cal APR-DRG 2017-18 Pricing …€¦ · 24-05-2017 · APR-DRG Description National Average Length of Stay HSRV Casemix Relative Weight Policy Adjustor -- NICU Policy
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Medi-Cal DRG 2017-18 Pricing Calculator
Medi-Cal DRG Pricing Calculator for FY 2017-18 Effective for Dates of Admission Between July 1 2017 and June 30 2018 May 22 2017 W17-888
This DRG Pricing Calculator is intended to enable hospitals and other interested parties to understand and predict estimated payment for inpatient stays covered by fee-for-service Medi-Cal This version applies to stays with dates of admission on or after July 1 2017 through June 30 2018 Annual updates necessitate a new calculator that reflects new wage index values hospital-specific base rates and other changes For stays with dates of admission prior to July 1 2017 see the DHCS DRG webpage In this file the Calculator sheet incorporates the pricing logic for the complete array of DRG pricing options The DRG Table tab shows information specific to each DRG The Hospital Characteristics tab shows information specific to each hospital The DRG Base Ratetab provides information related to wage area and base rate determination
Effective July 1 2017 outlier payments are to be calculated using a single cost outlier threshold with corresponding marginal cost percentage In previous years a two-tiered system was used to calculate payments
Under DRG payment the Medicaid claims processing system assigns each complete inpatient stay to an All Patient Refined Diagnosis Related Group (APR-DRG) based on the diagnoses and procedures on the claim (Note that Medi-Cal does not use Medicare DRGs which were not designed for a Medicaid population) Hospitals need not put the DRG on the claim and need not purchase APR-DRG software The Calculator tab assumes the user knows which APR-DRG applies to a particular stay For more information on APR-DRGs contact 3M Health Information Systems which developed and owns the software
This calculator is intended to be helpful to users to estimate pricing but it cannot capture all the editing and pricing complexity of the Medicaid claims processing system In cases of difference the claims processing system is correct
A Frequently Asked Questions document is available and is essential to understanding the payment method This DRG Pricing Calculator is also available in spreadsheet form as an interactive Excel file Both documents are at the Medi-Cal DRG page at httpwwwdhcscagov To sign up for the DRG listserv or to ask a DRG policy question email drgdhcscagov (Do not send any protected health information by email) For questions about claims contact the Medi-Cal Telephone Service Center at 8005415555
This calculator was developed by Conduent the fiscal intermediary for Medi-Cal It includes data obtained through the use of proprietary computer software created owned and licensed by the 3M Company All copyrights in and to the 3M TM Software are owned by 3M All rights reserved 3M bears no responsibility for the contents of this document
Tab 1- Cover 2017-05-22
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65
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Medi-Cal DRG 2017-18 Pricing Calculator
A B C D 2 - 3
15
11 Indicates information to be input by the user Indicates payment policy parameters set by Medi-Cal 12 Information Data COMMENTS OR FORMULA 13 14 $10000000
3000
INFORMATION FROM THE HOSPITAL -- TO BE ENTERED BY THE USER
4
Medi Cal DRG Pricing Calculator Effective Dates of Admission on or after July 1 2017 May 22 2017 Instructions 1 The hospital or other user inputs data in cells C14-C23 amp C34 Values for cell C34 can be found on the Hospital Characteristics tab
6 2 Medi-Cal payment policy parameters have already been entered in cells C35-C39 7 3 The calculator will show the predicted allowed amount and paid amount in cells C66 and C70 respectively 8 4 Length of Stay (LOS) = discharge date minus admission date If a patient is admitted and discharged on the same day the calculated LOS equals zero 9 5 Transfer discharge statuses include 02 05 63 65 66 82 85 91 93 and 94
6 This calculator spreadsheet is intended to be helpful to users but it cannot capture all the editing and pricing complexity of the Medi-Cal claims processing system In cases of difference the claims processing system is correct
Total charges UB-04 Form Locator 47 Hospital-specific cost-to-charge ratio Look up from Tab 4 Column H
16 Length of stay 10 No 25
$000 $000
No No
001-1
See instruction 4 used for transfer pricing adjustment
17 Patient discharge status = transfer See instruction 5 used for transfer pricing adjustment
18 Patient age (in years) Used for age adjustor
19 Other health coverage UB-04 Form Locator 54 for payments by third parties Patient share of cost Includes spend-down or copayment
21 Is discharge status equal to 30 Indicates an interim claim
22 Designated NICU facility Look up from Tab 4 Column E
23 APR-DRG From separate APR-DRG grouping software See values on Tab 3
24 APR-DRG INFORMATION -- CALCULATOR WILL FILL IN VALUES AUTOMATICALLY APR-DRG description LIVER TRANSPLANT
ampOR INTESTINAL TRANSPLANT
Look up from DRG table (Tab 3 Column B)
Casemix relative weight--unadjusted 70672 Look up from DRG table (Tab 3 Column D)
27 26
NICU service adjustor - hospital with designated NICU 10000 Look up from DRG table (Tab 3 Column J)
28 NICU service adjustor - all other hospitals 10000 Look up from DRG table (Tab 3 Column E)
29 Obstetric service adjustor 10000 Look up from DRG table (Tab 3 Column F) Pediatric age adjustor 14500 Look up from DRG table (Tab 3 Column H) Payment relative weight 70672 IF C18lt21 then if (C22=Yes) then (C26C27C29C30) else (C26C28C29C30)
else if (C22=Yes) then (C26C27C29) else (C26C28C29) 31
National average length of stay for this APR-DRG 655 Look up from DRG table (Tab 3 Column C)
33 32
PAYMENT POLICY PARAMETERS SET BY MEDI-CAL DRG base rate $7936 Specific to each hospital (Tab 4 Column L) Cost outlier threshold $60000 Threshold qualifying high and low-cost outlier adjustments
36
34
Marginal cost percentage 50 Used for high and low-cost outlier adjustments
37 Casemix adjustment factor 100 Used to adjust DRG relative weights should a need arise else leave set to 100
38 Interim claim threshold 29 Threshold qualifying interim claims
39 Interim per diem amount $600 Used for pricing interim claims
IS THIS AN INTERIM CLAIM Is discharge status equal to 30 No Look up C21
42 41
Is length of stay gt interim claim threshold NA IF C41=Yes then if (C16gtC38) Yes else No else NA
43 Skip to C70 for final interim claim payment amount $000 IF C42=Yes (C39C16) rounded to 2 places else 0
44 WHAT IS THE DRG BASE PAYMENT DRG base payment for this claim $5575314 C34C31C37
46 IS A TRANSFER PAYMENT ADJUSTMENT MADE Is a transfer adjustment potentially applicable No Look up C17
48 47
Calculated transfer payment adjustment NA IF C47=Yes then (C45C32)(C16+1) rounded to 2 places else NA
49 Is transfer payment adjustment lt allowed amount so far NA IF C48=NA then NA else if (C48ltC45) then Yes else No Allowed amount after transfer adjustment $5575314 IF C49=Yes then C48 else C45
51 IS A COST OUTLIER ADJUSTMENT MADE Estimated cost of this case $3000000 C14C15
53 52
Is estimated cost gt allowed amount Gain IF C52gtC50 then Loss else Gain
54 High-Side Outlier Payment When Payment Is Much Lower than Cost Estimated loss on this case NA IF C53=Loss then (C52-C50) else NA
56 Is loss gt outlier threshold lower limit NA IF C53=Loss then if (C55gtC35) then Yes else No else NA
57 DRG cost outlier payment increase $000 IF C56 =Yes then if (C55gtC35) then ((C55-C35)C36) else 0
58 Low Side Outlier Payment When Payment Is Much Greater than Cost Estimated gain on this case $2575314 IF C53=Gain then (C50-C52) elseNA Is gain gt outlier threshold No IF C53=Gain then if (C59gtC35) then Yes else No else NA DRG cost outlier payment decrease $000 IF C53=Gain then (if (C60=Yes) then (C59-C35)C36 rounded to 2 places else 0)
else 0
59
61
62 ALLOWED AMOUNT AFTER TRANSFER AND OUTLIER ADJUSTMENTS DRG payment so far $5575314 IF C53=Loss then (C50+C57) else (C50-C61)
64 63
CALCULATION OF ALLOWED AMOUNT AND REIMBURSEMENT AMOUNT Add-on amount $000 Hospital-specific payment separate from DRG payment (not used at this time)
66 Allowed amount $5575314 Allowed amount = C63+C65 67 Other health coverage $000 Look up C19 68 Patient share of cost $000 Look up C20
Lesser of calculation $5575314 Existing policy requires that payment amount cannot exceed total charges If C66gtC14 then C14 else C66 69
Payment amount 0 $5575314
If interim claim (C41=Yes) then interim claim (C43) amount is the payment amount Otherwise subtract other health coverage (C67) and patient share of cost (C68) from Lesser of (C69) to obtain payment amount
Tab 2- Calculator 2017-05-22
-Medi Cal DRG Table Effective July 1 2017 1 The DRG base payment equals the DRG base rate times the casemix relative weight times any applicable policy adjustors 2 Average length of stay and casemix relative weights were calculated from the Nationwide Inpatient Sample by 3M Health Information Systems for APR-DRG V34 3 Average length of stay is the untrimmed arithmetic value 4 Casemix relative weights reflect Hospital-Specific Relative Value (HSRV) relative weights V34 5 For purposes of illustration the table uses a DRG base rate of $7500 In fact DRG base rates are hospital specific See the Hospital Characteristics tab Column L for hospital specific DRG base rates 6 Pediatric is defined as under age 21 7 This table shows information for 1274 DRGs (318 base DRGs each with four levels of severity plus two error DRGs) 8 Inclusion of a service in this list does not necessarily imply coverage by Medi-Cal Rehabilitation services (APR-DRG 860) for example are paid outside the DRG method 9 This spreadsheet includes data obtained through the use of proprietary computer software created owned and licensed by the 3M Company All copyrights in and to the 3MTM Software are owned by 3M All rights reserved 3M has no responsibility for the contents of this calculator 10 This calculator was developed by Conduent the fiscal intermediary contractor for Medi-Cal
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
5
10
20
25
30
35
40
45
50
55
60
65
7
Medi-Cal DRG 2017-18 Pricing Calculator
A B C D 2 - 3
15
11 Indicates information to be input by the user Indicates payment policy parameters set by Medi-Cal 12 Information Data COMMENTS OR FORMULA 13 14 $10000000
3000
INFORMATION FROM THE HOSPITAL -- TO BE ENTERED BY THE USER
4
Medi Cal DRG Pricing Calculator Effective Dates of Admission on or after July 1 2017 May 22 2017 Instructions 1 The hospital or other user inputs data in cells C14-C23 amp C34 Values for cell C34 can be found on the Hospital Characteristics tab
6 2 Medi-Cal payment policy parameters have already been entered in cells C35-C39 7 3 The calculator will show the predicted allowed amount and paid amount in cells C66 and C70 respectively 8 4 Length of Stay (LOS) = discharge date minus admission date If a patient is admitted and discharged on the same day the calculated LOS equals zero 9 5 Transfer discharge statuses include 02 05 63 65 66 82 85 91 93 and 94
6 This calculator spreadsheet is intended to be helpful to users but it cannot capture all the editing and pricing complexity of the Medi-Cal claims processing system In cases of difference the claims processing system is correct
Total charges UB-04 Form Locator 47 Hospital-specific cost-to-charge ratio Look up from Tab 4 Column H
16 Length of stay 10 No 25
$000 $000
No No
001-1
See instruction 4 used for transfer pricing adjustment
17 Patient discharge status = transfer See instruction 5 used for transfer pricing adjustment
18 Patient age (in years) Used for age adjustor
19 Other health coverage UB-04 Form Locator 54 for payments by third parties Patient share of cost Includes spend-down or copayment
21 Is discharge status equal to 30 Indicates an interim claim
22 Designated NICU facility Look up from Tab 4 Column E
23 APR-DRG From separate APR-DRG grouping software See values on Tab 3
24 APR-DRG INFORMATION -- CALCULATOR WILL FILL IN VALUES AUTOMATICALLY APR-DRG description LIVER TRANSPLANT
ampOR INTESTINAL TRANSPLANT
Look up from DRG table (Tab 3 Column B)
Casemix relative weight--unadjusted 70672 Look up from DRG table (Tab 3 Column D)
27 26
NICU service adjustor - hospital with designated NICU 10000 Look up from DRG table (Tab 3 Column J)
28 NICU service adjustor - all other hospitals 10000 Look up from DRG table (Tab 3 Column E)
29 Obstetric service adjustor 10000 Look up from DRG table (Tab 3 Column F) Pediatric age adjustor 14500 Look up from DRG table (Tab 3 Column H) Payment relative weight 70672 IF C18lt21 then if (C22=Yes) then (C26C27C29C30) else (C26C28C29C30)
else if (C22=Yes) then (C26C27C29) else (C26C28C29) 31
National average length of stay for this APR-DRG 655 Look up from DRG table (Tab 3 Column C)
33 32
PAYMENT POLICY PARAMETERS SET BY MEDI-CAL DRG base rate $7936 Specific to each hospital (Tab 4 Column L) Cost outlier threshold $60000 Threshold qualifying high and low-cost outlier adjustments
36
34
Marginal cost percentage 50 Used for high and low-cost outlier adjustments
37 Casemix adjustment factor 100 Used to adjust DRG relative weights should a need arise else leave set to 100
38 Interim claim threshold 29 Threshold qualifying interim claims
39 Interim per diem amount $600 Used for pricing interim claims
IS THIS AN INTERIM CLAIM Is discharge status equal to 30 No Look up C21
42 41
Is length of stay gt interim claim threshold NA IF C41=Yes then if (C16gtC38) Yes else No else NA
43 Skip to C70 for final interim claim payment amount $000 IF C42=Yes (C39C16) rounded to 2 places else 0
44 WHAT IS THE DRG BASE PAYMENT DRG base payment for this claim $5575314 C34C31C37
46 IS A TRANSFER PAYMENT ADJUSTMENT MADE Is a transfer adjustment potentially applicable No Look up C17
48 47
Calculated transfer payment adjustment NA IF C47=Yes then (C45C32)(C16+1) rounded to 2 places else NA
49 Is transfer payment adjustment lt allowed amount so far NA IF C48=NA then NA else if (C48ltC45) then Yes else No Allowed amount after transfer adjustment $5575314 IF C49=Yes then C48 else C45
51 IS A COST OUTLIER ADJUSTMENT MADE Estimated cost of this case $3000000 C14C15
53 52
Is estimated cost gt allowed amount Gain IF C52gtC50 then Loss else Gain
54 High-Side Outlier Payment When Payment Is Much Lower than Cost Estimated loss on this case NA IF C53=Loss then (C52-C50) else NA
56 Is loss gt outlier threshold lower limit NA IF C53=Loss then if (C55gtC35) then Yes else No else NA
57 DRG cost outlier payment increase $000 IF C56 =Yes then if (C55gtC35) then ((C55-C35)C36) else 0
58 Low Side Outlier Payment When Payment Is Much Greater than Cost Estimated gain on this case $2575314 IF C53=Gain then (C50-C52) elseNA Is gain gt outlier threshold No IF C53=Gain then if (C59gtC35) then Yes else No else NA DRG cost outlier payment decrease $000 IF C53=Gain then (if (C60=Yes) then (C59-C35)C36 rounded to 2 places else 0)
else 0
59
61
62 ALLOWED AMOUNT AFTER TRANSFER AND OUTLIER ADJUSTMENTS DRG payment so far $5575314 IF C53=Loss then (C50+C57) else (C50-C61)
64 63
CALCULATION OF ALLOWED AMOUNT AND REIMBURSEMENT AMOUNT Add-on amount $000 Hospital-specific payment separate from DRG payment (not used at this time)
66 Allowed amount $5575314 Allowed amount = C63+C65 67 Other health coverage $000 Look up C19 68 Patient share of cost $000 Look up C20
Lesser of calculation $5575314 Existing policy requires that payment amount cannot exceed total charges If C66gtC14 then C14 else C66 69
Payment amount 0 $5575314
If interim claim (C41=Yes) then interim claim (C43) amount is the payment amount Otherwise subtract other health coverage (C67) and patient share of cost (C68) from Lesser of (C69) to obtain payment amount
Tab 2- Calculator 2017-05-22
-Medi Cal DRG Table Effective July 1 2017 1 The DRG base payment equals the DRG base rate times the casemix relative weight times any applicable policy adjustors 2 Average length of stay and casemix relative weights were calculated from the Nationwide Inpatient Sample by 3M Health Information Systems for APR-DRG V34 3 Average length of stay is the untrimmed arithmetic value 4 Casemix relative weights reflect Hospital-Specific Relative Value (HSRV) relative weights V34 5 For purposes of illustration the table uses a DRG base rate of $7500 In fact DRG base rates are hospital specific See the Hospital Characteristics tab Column L for hospital specific DRG base rates 6 Pediatric is defined as under age 21 7 This table shows information for 1274 DRGs (318 base DRGs each with four levels of severity plus two error DRGs) 8 Inclusion of a service in this list does not necessarily imply coverage by Medi-Cal Rehabilitation services (APR-DRG 860) for example are paid outside the DRG method 9 This spreadsheet includes data obtained through the use of proprietary computer software created owned and licensed by the 3M Company All copyrights in and to the 3MTM Software are owned by 3M All rights reserved 3M has no responsibility for the contents of this calculator 10 This calculator was developed by Conduent the fiscal intermediary contractor for Medi-Cal
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
-Medi Cal DRG Table Effective July 1 2017 1 The DRG base payment equals the DRG base rate times the casemix relative weight times any applicable policy adjustors 2 Average length of stay and casemix relative weights were calculated from the Nationwide Inpatient Sample by 3M Health Information Systems for APR-DRG V34 3 Average length of stay is the untrimmed arithmetic value 4 Casemix relative weights reflect Hospital-Specific Relative Value (HSRV) relative weights V34 5 For purposes of illustration the table uses a DRG base rate of $7500 In fact DRG base rates are hospital specific See the Hospital Characteristics tab Column L for hospital specific DRG base rates 6 Pediatric is defined as under age 21 7 This table shows information for 1274 DRGs (318 base DRGs each with four levels of severity plus two error DRGs) 8 Inclusion of a service in this list does not necessarily imply coverage by Medi-Cal Rehabilitation services (APR-DRG 860) for example are paid outside the DRG method 9 This spreadsheet includes data obtained through the use of proprietary computer software created owned and licensed by the 3M Company All copyrights in and to the 3MTM Software are owned by 3M All rights reserved 3M has no responsibility for the contents of this calculator 10 This calculator was developed by Conduent the fiscal intermediary contractor for Medi-Cal
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
591-3 NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE 7939 129706 12500 10000 162133 10000 162133 17500 226986 $121599 Neonate Neonate 591-4 NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE 10218 208522 12500 10000 260653 10000 260653 17500 364914 $195489 Neonate Neonate 593-1 NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE 1818 06043 12500 10000 07554 10000 07554 17500 10575 $5665 Neonate Neonate 593-2 NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE 5487 65483 12500 10000 81854 10000 81854 17500 114595 $61390 Neonate Neonate 593-3 NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE 6785 106916 12500 10000 133645 10000 133645 17500 187103 $100234 Neonate Neonate 593-4 NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE 8726 165242 12500 10000 206553 10000 206553 17500 289174 $154914 Neonate Neonate 602-1 NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 3070 27929 12500 10000 34911 10000 34911 17500 48876 $26183 Neonate Neonate 602-2 NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 4572 65324 12500 10000 81655 10000 81655 17500 114317 $61241 Neonate Neonate 602-3 NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 5775 90423 12500 10000 113029 10000 113029 17500 158240 $84772 Neonate Neonate 602-4 NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 7184 127344 12500 10000 159180 10000 159180 17500 222852 $119385 Neonate Neonate 603-1 NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION 1840 10282 12500 10000 12853 10000 12853 17500 17994 $9639 Neonate Neonate 603-2 NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION 3592 37980 12500 10000 47475 10000 47475 17500 66465 $35606 Neonate Neonate 603-3 NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION 4867 63606 12500 10000 79508 10000 79508 17500 111311 $59631 Neonate Neonate 603-4 NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION 6605 109740 12500 10000 137175 10000 137175 17500 192045 $102881 Neonate Neonate 607-1 NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 2574 27742 12500 10000 34678 10000 34678 17500 48549 $26008 Neonate Neonate 607-2 NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 3676 50494 12500 10000 63118 10000 63118 17500 88365 $47338 Neonate Neonate 607-3 NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 4670 70163 12500 10000 87704 10000 87704 17500 122785 $65778 Neonate Neonate 607-4 NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 5964 100958 12500 10000 126198 10000 126198 17500 176677 $94648 Neonate Neonate 608-1 NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION 1962 18028 12500 10000 22535 10000 22535 17500 31549 $16901 Neonate Neonate 608-2 NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION 3075 39171 12500 10000 48964 10000 48964 17500 68549 $36723 Neonate Neonate 608-3 NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION 4172 58169 12500 10000 72711 10000 72711 17500 101796 $54533 Neonate Neonate 608-4 NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION 5047 82164 12500 10000 102705 10000 102705 17500 143787 $77029 Neonate Neonate 609-1 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 350 12079 12500 10000 15099 10000 15099 17500 21138 $11324 Neonate Neonate 609-2 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 2056 36472 12500 10000 45590 10000 45590 17500 63826 $34193 Neonate Neonate 609-3 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 3724 69445 12500 10000 86806 10000 86806 17500 121529 $65105 Neonate Neonate 609-4 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 6188 123074 12500 10000 153843 10000 153843 17500 215380 $115382 Neonate Neonate 611-1 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 1485 15636 12500 10000 19545 10000 19545 17500 27363 $14659 Neonate Neonate 611-2 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 2233 28002 12500 10000 35003 10000 35003 17500 49004 $26252 Neonate Neonate 611-3 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 3521 48361 12500 10000 60451 10000 60451 17500 84632 $45338 Neonate Neonate 611-4 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 4421 75786 12500 10000 94733 10000 94733 17500 132626 $71049 Neonate Neonate 612-1 NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND 1807 22731 12500 10000 28414 10000 28414 17500 39779 $21310 Neonate Neonate 612-2 NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND 2615 34665 12500 10000 43331 10000 43331 17500 60664 $32498 Neonate Neonate 612-3 NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND 3444 49272 12500 10000 61590 10000 61590 17500 86226 $46193 Neonate Neonate 612-4 NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND 4282 72506 12500 10000 90633 10000 90633 17500 126886 $67974 Neonate Neonate 613-1 NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION 1558 18066 12500 10000 22583 10000 22583 17500 31616 $16937 Neonate Neonate 613-2 NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION 2178 26588 12500 10000 33235 10000 33235 17500 46529 $24926 Neonate Neonate 613-3 NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION 3336 46993 12500 10000 58741 10000 58741 17500 82238 $44056 Neonate Neonate 613-4 NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION 4586 61563 12500 10000 76954 10000 76954 17500 107735 $57715 Neonate Neonate 614-1 NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION 1143 09292 12500 10000 11615 10000 11615 17500 16261 $8711 Neonate Neonate 614-2 NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION 1993 22855 12500 10000 28569 10000 28569 17500 39996 $21427 Neonate Neonate 614-3 NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION 2992 38167 12500 10000 47709 10000 47709 17500 66792 $35782 Neonate Neonate 614-4 NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION 3150 46161 12500 10000 57701 10000 57701 17500 80782 $43276 Neonate Neonate 621-1 NEONATE BWT 2000-2499G W MAJOR ANOMALY 760 05669 12500 10000 07086 10000 07086 17500 09921 $5315 Neonate Neonate 621-2 NEONATE BWT 2000-2499G W MAJOR ANOMALY 1522 16241 12500 10000 20301 10000 20301 17500 28422 $15226 Neonate Neonate 621-3 NEONATE BWT 2000-2499G W MAJOR ANOMALY 2166 30613 12500 10000 38266 10000 38266 17500 53573 $28700 Neonate Neonate 621-4 NEONATE BWT 2000-2499G W MAJOR ANOMALY 3316 59337 12500 10000 74171 10000 74171 17500 103840 $55628 Neonate Neonate 622-1 NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND 1155 13970 12500 10000 17463 10000 17463 17500 24448 $13097 Neonate Neonate 622-2 NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND 1570 21235 12500 10000 26544 10000 26544 17500 37161 $19908 Neonate Neonate 622-3 NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND 2078 31351 12500 10000 39189 10000 39189 17500 54864 $29392 Neonate Neonate 622-4 NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND 2475 47226 12500 10000 59033 10000 59033 17500 82646 $44274 Neonate Neonate 623-1 NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION 921 09677 12500 10000 12096 10000 12096 17500 16935 $9072 Neonate Neonate 623-2 NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION 1448 16910 12500 10000 21138 10000 21138 17500 29593 $15853 Neonate Neonate 623-3 NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION 2058 27833 12500 10000 34791 10000 34791 17500 48708 $26093 Neonate Neonate 623-4 NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION 2787 40703 12500 10000 50879 10000 50879 17500 71230 $38159 Neonate Neonate 625-1 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 1175 11279 12500 10000 14099 10000 14099 17500 19738 $10574 Neonate Neonate 625-2 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 1680 18927 12500 10000 23659 10000 23659 17500 33122 $17744 Neonate Neonate 625-3 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 2119 26173 12500 10000 32716 10000 32716 17500 45803 $24537 Neonate Neonate 625-4 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 1866 39129 12500 10000 48911 10000 48911 17500 68476 $36683 Neonate Neonate 626-1 NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 276 01341 10000 10000 01341 10000 01341 10000 01341 $1006 Normal newborn Normal newborn 626-2 NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 439 02386 10000 10000 02386 10000 02386 10000 02386 $1790 Normal newborn Normal newborn 626-3 NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 874 07567 10000 10000 07567 10000 07567 10000 07567 $5675 Normal newborn Normal newborn 626-4 NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 1608 25107 10000 10000 25107 10000 25107 10000 25107 $18830 Normal newborn Normal newborn 630-1 NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE 388 18284 12500 10000 22855 10000 22855 17500 31997 $17141 Neonate Neonate 630-2 NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE 577 25699 12500 10000 32124 10000 32124 17500 44973 $24093 Neonate Neonate 630-3 NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE 1077 41010 12500 10000 51263 10000 51263 17500 71768 $38447 Neonate Neonate 630-4 NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE 2816 87237 12500 10000 109046 10000 109046 17500 152665 $81785 Neonate Neonate 631-1 NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE 281 09956 12500 10000 12445 10000 12445 17500 17423 $9334 Neonate Neonate 631-2 NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE 544 12584 12500 10000 15730 10000 15730 17500 22022 $11798 Neonate Neonate 631-3 NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE 1559 25671 12500 10000 32089 10000 32089 17500 44924 $24067 Neonate Neonate 631-4 NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE 3999 75844 12500 10000 94805 10000 94805 17500 132727 $71104 Neonate Neonate 633-1 NEONATE BIRTHWT gt2499G W MAJOR ANOMALY 287 02016 12500 10000 02520 10000 02520 17500 03528 $1890 Neonate Neonate 633-2 NEONATE BIRTHWT gt2499G W MAJOR ANOMALY 540 05299 12500 10000 06624 10000 06624 17500 09273 $4968 Neonate Neonate
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
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Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
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Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
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Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
APR -DRG -APR DRG Description
National Average Length of Stay
HSRV Casemix Relative Weight
Policy Adjustor --NICU
Policy Adjustor --Obstetrics
Payment Relative --Weight
No Age Adjustor Policy Adjustor --Pediatric Age
Payment --Relative Weight
with Age Adjustor
Policy Adjustor --Service (Designated NICUs)
Payment Relative Weight with Designated NICU Adjustor
DRG Base Payment Using Example Base Rate $7500
Medicaid Care Category --Pediatric
Medicaid Care Category --Adult
850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 3- DRG Table 2017-05-22
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that
has at least a basic level emergency room H SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor
09792) Wage index value times 09792 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls
for changes between California and the rest of the US while maintaining relative differences among wage areas within California K SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J
M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18
N SFY 2017-18 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 O SFY 2017-18 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2017-18 These
services are indicated by use of Revenue Code 199
A B C D E F G H I J K L M N O
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated Remote Rural
SFY 17-18 CCR
FFY 2017 Wage Index Value
FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
SFY 17-18 Unadjusted
Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted statewide base rate
SFY 17-18 Rehab rate
SFY 17-18 ADMIN 2 190 rate
SFY 17-18 ADMIN 2 199 Rate
OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
OSHPD ID Name DPH NDPH
Designated NICU as
Defined by DHCS
OSHPD Rural Hospital
DHCS Designated
Remote Rural SFY 17-18 CCR FFY 2017 Wage
Index Value
FFY 2017 Wage Index Value (Adjusted for
CA Neutrality Factor 09792)
SFY 17-18 Unadjusted Remote Rural Statewide Base Rate
SFY 17-18 Wage Adjusted Statewide Base Rate
SFY 17-18 Rehab Rate
SFY 17-18 ADMIN 2 190
Rate
SFY 17-18 ADMIN 2 199
Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017
Medi-Cal DRG 2017-18 Pricing Calculator
Tab 4- Hospital Characteristics 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
Medi-Cal DRG 2017-18 Pricing Calculator
DRG Base RateFor each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors
1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for SFY 2017-18 is $6760
2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments that Medicare uses(from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been multiplied by 09792 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space
Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
CBSA Number
SFY 2017-18 Wage Index ValueMedicare Wage Area
05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609
12766
$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786
16962
$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065
Tab 5- DRG Base Rate 2017-05-22
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017
Tab 5- DRG Base Rate 2017-05-22
1-Cover
2-Calculator
3-DRG Table
4-Hospital Characteristics
5-DRG Base Rate
Tab5completepdf
5-DRG Base Rate
Tab52ndpagepdf
5-DRG Base Rate
Tab2pdf
2-Calculator
Tab3 0523pdf
3-DRG Table
Tab5 complete 523pdf
5-DRG Base Rate
Tab 4 9pmpdf
4-Hospital Characteristics
Medi-Cal DRG 2017-18 Pricing Calculator
CBSA Number Medicare Wage Area
Wage Area Index Values
SFY 2017-18 Wage Index Value
SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)
Statewide Base Rate ($6760) Adjusted by Wage Area
Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area
42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065
Source CMS Medicare inpatient final rule for FFY 2017