Inpatient claim

 

Reference parity · 5,000 of 5,000 test claims within $1.00
Inputs changed since this price · Price claim Ctrl Enter

Claim

Hospital: the UB-04 paid by MS-DRG. Physician: the doctors’ 837P claims for the same stay.

Each doctor or practitioner who treated the patient during the stay bills their own claim (837P), paid on top of the hospital’s DRG payment. One block per practitioner; inpatient services are POS 21.

On an anesthesia line, Units are the anesthesia minutes.

Fictional test claims: made-up patients priced on real hospitals' published rates. Each loads into Full claim, and nothing is priced until you press Price claim.

Quick DRG prices one MS-DRG at a hospital. Full claim takes the claim as it reads on the UB-04: it groups the diagnosis and procedure codes first (free) and checks the billed DRG; pricing uses one priced claim.

Paste codes, a claim (JSON) or an 837I

Codes: principal diagnosis first, POA after a colon (R65.21:Y) or as the next item (R65.21 Y), procedures after px:. A JSON claim or an 837I starts a new claim; codes alone keep the rest of the claim on screen. An 837I is read in your browser: names, member IDs and dates of birth are never read or sent.

    Attending NPI / Operating NPI optional · provider screening only

    After the claim is priced, these and the hospital's NPI are checked against the OIG exclusion list (LEIE). They change no amount.

    Dates of service from admit to discharge

          Checked against our regrouping of the codes.
          Diagnoses FL67 · 67A–Q

          POA: Y present · N not present · U documentation insufficient · W clinically undetermined · 1 exempt · – blank, not reported

          Principal diagnosis and POArequired
          Other diagnoses and POA
          Procedures FL74 · 74a–e

          Payment

          Regrouping check

          Checks

          Checks Out of date

          • ChecksPrice a claim to run them

          Provider record Out of date

          More on the rate period

          Reference parity

          Not run
          Price the claim through CMS Web Pricer (webpricer.cms.gov) and compare. Needs a discharge date, covered days and covered charges.

          Uses 1 priced claim

          DRG family and transfer Out of date

          same claim, each severity
            Code only what the record supports.

            Access and limits

            Free tier

            Enterprise · API key

            An API key lifts these limits: every MS-DRG, no daily cap, and batches of up to 200 claims.

            Get an API key

            The key stays in this tab’s session storage and goes only in the X-API-Key header of this site’s requests (batch, import, verify and compare too): never in links, exports or memos. Closing the tab forgets it, and checking a key uses no priced claim.

            Start from a claim that is already priced

            Each opens a saved sample with its answer on screen; change any input and price your own.

            Every tool (30)

            Grouped as in the menus at the top of every page.

            Price a claim

            Check claims

            Model a contract

            Coding and CDI

            Look up

            Pricing at volume? Send 50 de-identified claims and get a repricing and DRG-variance report back.

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            How Inpatient (IPPS DRG) pricing works

            Enter the claim the way it reads on the UB-04: the hospital by CCN, NPI or name, the admit and discharge dates, the patient discharge status, total and covered charges, and either the MS-DRG (Quick DRG) or the diagnosis and procedure codes with present-on-admission indicators (Full claim). Covered days are worked out from the dates and can be overridden. The discharge date sets the rate year: discharges on or after October 1, 2026 price under FY2027 rates and group under MS-DRG v44; earlier discharges price under their own fiscal year, back to FY2023 (October 1, 2025 to September 30, 2026 under FY2026, October 1, 2024 to September 30, 2025 under FY2025, and so on).

            In Full claim the codes are regrouped for free and the result is checked against the billed DRG before anything is priced. Pricing then builds the payment the way the inpatient prospective payment system does: the DRG weight times the wage-adjusted standardized amount, teaching and low-income add-ons, capital, uncompensated care, quality adjustments, pass-through, the transfer per-diem and any cost outlier, on the hospital's provider record in force on the discharge date.

            Every result shows the claim four ways for payers and TPAs: Original Medicare, Medicare Advantage out of network, a reference-based price at a percent of Medicare you set (on Original Medicare without pass-through by default, with your plan's carve-outs, outlier rule, floor, cap and lesser-of-billed-charges rule, modeled in your browser), and billed charges with the discount. The repricing worksheet, EOB remark and claim note copy straight into a claim system.

            Questions

            Is this the CMS Web Pricer?

            No. It is an independent tool built on the published IPPS rates and provider data. You can check any priced claim against the CMS Web Pricer from the page; on the showcase claim, an FY2027 discharge, the two agree within $0.07.

            Which date sets the rate year?

            The discharge date. A stay admitted in September and discharged on or after October 1 prices under the new fiscal year's rates and groups under the new MS-DRG version. The admit date only counts the covered days.

            Does the DRG payment include the doctors?

            No. The DRG payment is the hospital’s. The surgeon, anesthesiologist, nurse anesthetist, hospitalist, radiologist and other practitioners each bill their own professional claim (837P), paid on the physician fee schedule, or for anesthesia on base and time units. The Physician (837P) tab prices those claims next to the hospital’s payment, so the whole stay adds up in one place.

            Why is the Medicare Advantage amount lower?

            A plan paying a non-contracted hospital owes what Original Medicare would pay, less the amounts Medicare pays the hospital directly: operating indirect medical education and pass-through costs. Capital indirect medical education and disproportionate share stay in. Uncompensated care is kept in the plan share too; that is an assumption, because the 2010 out-of-network payment guidance predates uncompensated care payments.

            What is the reference-based price?

            A percent of the Medicare amount that you set, 150% by default, on a base you choose: Original Medicare less pass-through by default, with optional carve-outs, an outlier rule, a floor, a cap and a lesser-of-billed-charges rule. It is arithmetic in your browser on the Medicare figure, labeled modeled, and is not a Medicare payment.

            Which DRGs are free?

            The free tier prices 40 common MS-DRGs at any hospital, with a daily limit of priced claims per network. Grouping is always free. An API key, entered on the page, prices every DRG.

            Most-priced MS-DRGs

            What Medicare paid hospitals for each, nationally, by state and by hospital: