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 FY2027 rates PayerParityLoads a real 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.
Off by default: the headline is Original Medicare (fee-for-service, non-HMO). Check it for a claim a Medicare Advantage plan (HMO or PPO) pays to a hospital outside its network — CMS’s Web Pricer calls this “HMO Paid Claim = Yes”. The plan pays the same claim less the operating IME and most of the per-diem pass-through, which Medicare pays the hospital directly; an in-network MA claim pays the plan’s contract rate instead. Both amounts are always shown under the headline.
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: 766 MS-DRG relative weights & length-of-stay values (FY2027; 770 for FY2026); hospital-specific wage indices by CCN (3,253 IPPS hospitals); national FY2027 and 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 $49,331 (FY2027, as corrected by CMS-1849-CN3; $40,397 for 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
Original Medicare (fee-for-service, non-HMO) = operating (base × [1 + IME + DSH]) + capital + uncompensated care + value-based purchasing and readmissions + cost outlier. Medicare Advantage out of network is what CMS's pricer calls an HMO paid claim; the flag covers every MA plan, HMO or PPO. It is the same claim less the operating IME, which Medicare pays the hospital directly; the outlier does not change. An in-network MA claim pays the plan's contract rate instead. Both sides price on the provider record in force on the discharge date, through CMS's own Inpatient PPS pricer. The per-diem pass-through is left out of both, because CMS's pricer API leaves it out of its total.
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.