Diagnosis Related Grouping

Wyoming Medicaid pays inpatient hospitalizations by using the All Patient Refined Diagnosis Related Grouping (APR DRG) methodology. Diagnosis Related Groups (DRGs) are used by providers and payers to classify patients into clinically-related “groups” for Inpatient Services. DRGs allow providers and payers to categorize complex patient claims data for analysis and payment.

  • Cover – An introduction to the DRG Pricing Calculator and additional locations where interested parties can learn more about the Wyoming Medicaid Inpatient DRG pricing method.
  • Structure – A synopsis of the information provided in the DRG Calculator spreadsheet
  • Calculator Instructions – A description of the data that must be entered to estimate the Wyoming Medicaid payment amount for an inpatient hospital stay. The instructions also describe the calculations being made to determine the payment amount.
  • Interactive Calculator – Calculator whereby providers and users can enter just a few data elements describing an individual hospital charge (located at the top of the calculator), and then an estimate of the Wyoming Medicaid payment for that discharge will be displayed (at the bottom of the calculator).
  • DRG Table – A list of the APR DRG codes and parameters used in pricing inpatient hospital stays.
  • Provider Table – A lookup option for use in determining pricing for non-par hospitals. Also includes each provider’s numerical parameters used in the DRG pricing calculation. Cost-to-Charge Ratios (CCRs) reflect the aggregate CCR for each provider. In addition to the participating hospitals, there is a lookup option of “NON PAR HOSP” for use in determining pricing for all other hospitals.

Note: The DRG Calculator is intended only for non-participating providers. (Hospitals that do not have provider-specific APR DRG rates).