The whole engine in 60 seconds
Group ICD-10 codes to an MS-DRG, watch one documented MCC move DRG 195 → 193 (+$5,580.76), see the full FY2026 payment build line by line, the 2.5× swing between two hospitals, a live match against the official pricer to the cent, and every estimate exported as a PDF/Excel pricing worksheet. Every figure is real engine output.
DRG Pricer MS-DRG v43.1 FY2026 PayerParityLoads a real FY2026 example at Houston Methodist. Toggle the severity to watch one documented MCC change the DRG and the payment — or search your own DRG and hospital below.
Enter admit & discharge dates (LOS is computed), or type LOS directly. It's compared against the DRG's mean stays in the estimate.
IME & DSH default to the provider's CMS values (from its resident-to-bed and low-income patient ratios). Uncheck to see the payment without a given add-on.
Leave unchecked for standard in-network pricing. Check only for out-of-network MA paid claims — it caps the payment at the Medicare-equivalent floor.
Payment breakdown
Formula & data coverage
Operating = [(Labor SA × Wage Index) + Nonlabor SA] × Weight × (1 + IME_op + DSH_op) Capital = (Capital Rate × GAF × Weight) × (1 + IME_cap + DSH_cap) Grand Total = Operating + Capital + Uncompensated Care + Outlier (if cost exceeds threshold)
Coverage: 770 MS-DRG relative weights & length-of-stay values; hospital-specific wage indices by CCN (3,253 IPPS hospitals); national FY2026 standardized amounts; and hospital-specific financials — operating/capital cost-to-charge ratios, IME & DSH adjustment factors, GAF, uncompensated-care per-claim amount, and Hospital-Specific Payment rate (3,103 hospitals). Outlier fixed-loss threshold $40,397 (FY2026).
Not modeled: reconciliation of a hospital's prior-year cost report — IME/DSH/CCR figures here are the FY2026 rule's modeled estimates (the same inputs Medicare uses going into the year); actual settlement can differ slightly. Hospitals without a published wage index — critical access, VA, inpatient psych/rehab (IPF/IRF), long-term care (LTCH) — are paid under other systems this calculator doesn't model; enter a wage index manually for those.
Search by partial name or CCN — or just pick a state, city or ZIP to browse. Use ↑/↓ and Enter to select. Each result shows wage index and teaching status; select one for its full Medicare payment-factor profile.
Hospital profile
Leave unchecked for standard in-network Medicare/MA pricing (the usual case, and what matches CMS and a third-party pricer). Check only for a genuinely out-of-network MA paid claim — it caps the payment at the Medicare-equivalent floor.
Edit as JSON (API shape)
The form and this JSON stay in sync — edit either. Fields: drgCode, ccn|wageIndex, scenario, coveredCharges, los, transferStatus, hmoPaidClaim, npi, referenceTotal.
Claim result
Accepted fields
Assigns the MS-DRG from the diagnoses (and procedures) only — no payment. Four shapes auto-convert: our native format (diagnoses [{code, poa}], procedures, age, sex, dischargeStatus), a vendor PatientClaim/Dx claim, a FHIR R4 Claim resource (diagnosis codings, billablePeriod, provider.identifier → CCN), and an Epic Tapestry-style claim. Pick one from the sample menu, edit, and re-run. To price the result too, use the Group & price tab.
Grouped DRG
Accepted fields
Groups the claim to an MS-DRG and prices it. Needs a facility (ccn / facility / FHIR provider.identifier / Tapestry Facility.CCN) plus optional charges and stay dates for the payment. Four shapes auto-convert: native, vendor PatientClaim/Dx, FHIR R4 Claim, and Epic Tapestry-style. Pick one from the sample menu, edit, and re-run.
Grouped & priced
Verify against CMS
Prices the same claim through our engine and CMS's own Inpatient PPS pricer live, side by side. A sample claim loads by default — edit the fields and re-run to compare your own.
How the match works
CMS's per-claim payment = operating (base × [1 + IME + DSH]) + capital + uncompensated-care + value-based-purchasing + cost outlier. We call CMS's own Inpatient PPS pricer with the provider's current record and show both numbers. Small differences are cost-to-charge-ratio data vintage, not formula differences. Organ/DME/stem-cell pass-through is shown by CMS but not paid per claim (cost-report settled), so it is excluded from both totals.
Our estimate vs CMS
Outpatient pricing
One module, multiple outpatient payment systems. Medicare rates are the official July 2026 tables (CMS-1834-FC), wage-adjusted; EAPG prices with your payer's factors.
Formulas & sources
OPPS: adjusted rate = national rate × [(0.60 × wage index) + 0.40] (42 CFR 419.43). ASC: adjusted rate = national rate × [(0.50 × wage index) + 0.50]; beneficiary coinsurance is 20% of the adjusted rate. Rates from the July 2026 OPPS Addendum B and ASC Addendum AA; packaged/not-paid status indicators pay $0 separately. EAPG: payment = payer base rate × relative weight × units, less consolidation discounting (repeat-ancillary / multiple-procedure lines commonly discount 50%; packaged lines pay $0) — weights and base rates come from your payer or state, never estimated here.
Outpatient payment
NY Medicaid inpatient — APR-DRG
NY Medicaid prices acute inpatient stays with 3M APR-DRGs (grouper v34), not MS-DRGs. This prices a FFS discharge from the state-published weight table and per-hospital rates (NY DOH, 1/1/2025 rate period): SIW × the hospital's case-payment rate, plus IME, capital and DME.
Alternate-level-of-care days — paid per diem at the hospital's ALC rate on top of the case payment.
Method & sources
Operating = SIW × the hospital's per-discharge case-payment rate; IME is the teaching add-on (% of operating); capital and DME are per-discharge amounts — all from the NY DOH published rate files. Cost-outlier add-ons apply only when audited costs exceed the DRG's threshold (shown for reference); per-diem transfer and short-stay logic are not modeled. APR-DRG assignment (diagnoses → DRG + SOI) is 3M/Solventum-licensed software — you supply the DRG, exactly as the Claim pricer takes an MS-DRG. Sources: NY DOH APR-DRG weights · FFS rates.
NY Medicaid payment
Texas Medicaid inpatient — APR-DRG
Texas Medicaid prices acute inpatient stays with 3M APR-DRGs (grouper v40), not MS-DRGs. Prospective payment is the hospital's Standard Dollar Amount (SDA) × the APR-DRG relative weight — the SDA already folds in wage, IME, trauma and safety-net add-ons. Rural and children's hospitals carry enhanced SDAs.
Method
Payment = the hospital's Standard Dollar Amount (SDA) × the APR-DRG relative weight (SFY2026, Grouper V40). The SDA already incorporates wage, IME, trauma and safety-net add-ons, so no separate factors apply. Day- and cost-outlier add-ons apply to qualifying stays and aren't computable from a claim alone (the day-outlier threshold is shown for reference); obstetric deliveries use the hospital's delivery SDA where applicable. APR-DRG assignment (diagnoses → DRG + SOI) is 3M/Solventum-licensed software — you supply the DRG, exactly as the Claim pricer takes an MS-DRG.
Texas Medicaid payment
New York Medicaid — Rate Codes & HARP
NY Medicaid pays many services by rate code — a 4-digit code identifying a payment rate and methodology on institutional / managed-care claims (837I · UB-04, value-code field) — rather than by HCPCS/CPT on the practitioner fee schedule. This tab covers the rate codes behind HARP behavioral-health HCBS, clinic (MHOTRS), and FQHC services, plus who can bill them.
Rate-code reference
| Rate code | Category | Service | HCPCS × mod | Unit | Rate · Downstate |
|---|
HARP HCBS rows show the real Downstate (NYC-region) fee-schedule rate and the HCPCS × modifier crosswalk. Clinic (MHOTRS) and FQHC rows are rate-based (APG base × weight / PPS per-visit) and provider-specific, so they show the basis rather than a flat fee. Upstate fees differ — verify against the payer before billing.
Who can bill HARP BH HCBS
HARP HCBS uses a two-step, managed-care billing flow — the plan bills the state payer under the rate code; the designated provider bills the plan at the fee-schedule amount:
- Rendering professional matters for CPST: the rate code differs by who provides it — 7790 physician · 7791 NP / psychologist · 7792 RN, LMHC, LMFT, LCSW, LMSW · 7793 all other allowable professions.
- Provider side: must be State-designated for the specific BH HCBS and contracted with the HARP plan / HIV-SNP.
- Enrollee side: HARP enrollees are adults 21+ with significant behavioral-health need; BH HCBS requires an eligibility assessment by a State-designated assessing entity (typically a Health Home care manager).
NY provider lookup
Search NY providers — FQHC/RHC (by NPI) and hospitals (by op-cert) — by name or ID. Shows each provider's default rate (FQHC PPS per-visit / hospital APR-DRG base).
Billing reference
Verify current codes and fee-schedule amounts against the payer before billing.
NY Medicaid outpatient — EAPG
NY Medicaid pays most outpatient, clinic, and ambulatory-surgery visits with EAPGs (Enhanced Ambulatory Patient Groups) — a visit-based grouper: every line on the claim maps to an EAPG, and the payment is built from the provider's base rate and each line's EAPG weight.
How an EAPG visit prices
- Provider base rates are provider-specific — each clinic / hospital OPD has its own state-published operating base rate (plus capital add-on).
- EAPG weights are statewide — one weight table, updated by the state; the same weight applies at every provider.
- Discounting: multiple significant procedures in one visit pay full weight on the first line and a discounted percentage on the rest; ancillaries package into the visit when routine.
Price an EAPG line now
The Outpatient module prices EAPG lines today with your payer's factors — enter the base rate and weight from your contract or the state schedule. Statewide weight tables and per-provider base rates load into the database next, alongside the APR-DRG tables.
Batch analytics
Retrospective revenue analysis — 10 discharges per call (an API key raises this to 200). Paste CSV with headers drgCode, ccn, los, coveredCharges (only drgCode + ccn required), or load the sample. Bad rows report their error without failing the batch.
Batch results
Contract modeling
Set the Medicare baseline for a DRG at a hospital, then model your payer contracts against it — percent-of-Medicare or flat case rates. Terms are yours to edit and stay in this browser only.
Multipliers and case rates here are illustrative placeholders, not real payer rates — enter your contracted terms. Saved locally in your browser; nothing is uploaded.
Expected payment by payer
Clinical coding
Each code's CC/MCC classification comes from the real v43.1 severity tables once grouped.
The scanner surfaces high-yield CDI targets documented in the note but missing from the coded list, checked against the official severity tables. With model credentials on the server it upgrades to a full AI scan — still table-validated.
Documentation integrity: CDI Assist only surfaces conditions explicitly documented in the note but missing from the coded diagnoses — documentation completeness, not severity inflation. Code only what is clinically present and supported in the record.