Inpatient Prospective Payment System · A real FY2026 claim
It agrees with CMS. To the dollar.
Group any inpatient claim, price it under the IPPS, and verify it live against the official CMS pricer — the authoritative source. Here is one real claim, priced both ways; the 5,000-claim study checks the rest.
Scrolls through each scene on its own. Scroll or press Escape to stop.
One claim, priced two waysReconciled
| CMS pricerlive · official Inpatient PPS | $8,617.39 |
|---|---|
| This toolself-contained engine | $8,616.85 |
| Difference | $0.54 · 0.006% |
DRG 291 · Heart failure & shock w/ MCCWeight 1.2838Saint Luke's South · CCN 170185
The proof
Every case tracks the authoritative pricer.
These are real claims run through our engine and cross-checked against the CMS pricer. Same DRG, same relative weight, totals within a rounding cent. The full check is the 5,000-claim accuracy study: synthetic inpatient claims at 60 hospitals, every one within $1.00 of the CMS Web Pricer (run October 23, 2026).
| MS-DRG and case | This tool | CMS pricer Reference | Difference |
|---|---|---|---|
| Heart failure & shockwith MCC · weight 1.2838 | |||
| 291Heart failure & shockwith MCC · weight 1.2838 | $8,616.85 | $8,617.39 | −$0.54 |
| Pulmonary edema & respiratory failurecost outlier · weight 1.2354 | |||
| 189Pulmonary edema & respiratory failurecost outlier · weight 1.2354 | $21,380.28 | $21,380.45 | −$0.17 |
| Respiratory system dx w/ ventilator <96hcost outlier · $392,290 charges | |||
| 208Respiratory system dx w/ ventilator <96hcost outlier · $392,290 charges | $23,394.34 | $23,394.67 | −$0.33 |
| Septicemia / severe sepsiswith MCC · weight 1.9425 | |||
| 871Septicemia / severe sepsiswith MCC · weight 1.9425 | $13,038.04 | $13,038.86 | −$0.82 |
| Simple pneumonia & pleurisywithout CC/MCC · weight 0.6285 | |||
| 195Simple pneumonia & pleurisywithout CC/MCC · weight 0.6285 | $4,218.49 | $4,218.75 | −$0.26 |
| Five cases | $70,648.00 | $70,650.12 | −$2.12 |
The residual cents are input precision, not formula — CMS carries the provider's HRRP/VBP factors to more decimals than the published PSF. The operating base matches to the penny.
The pipeline
Group. Price. Verify.
Three moves take a coded claim to a payment you can defend — the last one is a live call to CMS, so you are never guessing.
01 · Group
ICD-10 to MS-DRG
A self-contained grouper on the CMS MS-DRG tables, v39 to v44 — MDC, CC/MCC severity, surgical hierarchy.
- PrincipalA41.9Sepsis
- SecondaryR65.21 MCCSeptic shock
- MS-DRG871w/ MCC
02 · Price
Full IPPS build
Operating + capital, wage index, IME & DSH, uncompensated care, and high-cost outliers.
An IPPS build, by component Component Amount Operating base $8,012.20 Capital / IME / DSH $623.10 Outlier (if any) $0.00 03 · Verify
Live vs CMS
One click prices the same claim through the official CMS pricer, side by side.
Our estimate and the CMS pricer, side by side Our estimate $8,616.85 CMS pricer $8,617.39 Verdict Matches CMS
The full toolkit
Every tab, one engine.
Fourteen tools, grouped by the job, on the same pricing core — from a quick single-DRG estimate to a coded claim grouped, priced, and checked against the official pricer, live.
Price
- Inpatient (IPPS DRG)A Medicare inpatient claim priced from its dates, codes and charges, with free DRG regrouping.
- SNF claimThe PDPM per diem from each 0022 line's HIPPS code and days, with consolidated billing.
- Professional claimAn 837P at any place of service, at the facility or non-facility rate.
- OutpatientA hospital outpatient claim, line by line, with APC packaging and claim edits.
- MedicaidInpatient stays by APR-DRG in New York, Texas, Colorado, Virginia and Washington.
Check
- Grouper and CDIICD-10 codes to an MS-DRG, with the grouping path, the CC and MCC drivers and the DRG family.
- Verify vs CMSAny claim, priced by our engine and by CMS's own pricer in the same view — live, side by side, with a match verdict. $23,394.65 vs $23,394.67 on the sample case.
- DRG compareUp to four MS-DRGs at one hospital, one DRG at four hospitals, or FY2026 vs FY2027 rates.
Bulk work
Reference
- National insightsWhere Medicare's 2024 inpatient dollars went, by MS-DRG and by state.
- HospitalsAny hospital by name, CCN or NPI: wage index, CBSA, teaching status and case-mix index.
- ContractsPayer contract terms modeled against the Medicare baseline for a DRG and hospital.
- NewsPlain-English Medicare and Medicaid payment analysis for payers and TPAs.
Also on the site: the Grouping sandbox, the grouper as a glass box with a self-playing demo of two examples, and Integrations, twelve connectors for payer platforms.
Why the DRG lands where it does
You can see what drives the severity.
Add a secondary diagnosis or an OR procedure and the grouper shows exactly which code moved the DRG — the CC/MCC that carries the weight is marked, with the base DRG range it selects within.
DRG 871Severe sepsis · w/ MCC
base range 870–872
| Code | Description | Role |
|---|---|---|
| A41.9 | Sepsis, unspecified organism | Principal |
| R65.21 | Severe sepsis w/ septic shock | MCC driver |
| E11.9 | Type 2 diabetes | No CC/MCC |
- Severity driver
Drop the MCC and the same claim falls to DRG 872 — a different weight, a different payment.
This card is read-only; the live sandbox re-runs the real decision path — and the real dollars — as you toggle each code.
Integration-ready
The pricing engine, wired to the systems that consume it.
Twelve connectors for the platforms that price and adjudicate DRG claims — core admin, contract modeling, and clearinghouses. Each goes live on its own credentials; until then it runs a real sandbox that still groups and prices for real.
| Platform | Capabilities |
|---|---|
| Core claim administration | |
| FacetsCognizant TriZetto | DRG pricing · Adjudication |
| QNXTCognizant TriZetto | DRG pricing · Adjudication |
| HealthRules PayerHealthEdge | DRG pricing · Modeling |
| Payer PlatformsPLEXIS | DRG pricing |
| TapestryEpic | DRG pricing · Adjudication |
| Oracle Health (Cerner)Oracle | DRG pricing · Adjudication |
| Contract pricing & modeling | |
| NetworX PricerCognizant TriZetto | DRG pricing · Modeling |
| NetworX ModelerCognizant TriZetto | Modeling |
| Claims Edit SystemOptum | DRG pricing |
| Clearinghouses | |
| Availity EssentialsAvaility | Eligibility · Remittance |
| Change HealthcareOptum Insight | Eligibility · Remittance |
| WaystarWaystar | Eligibility · Remittance |
A live round-trip
Send a claim to NetworX, get both prices back.
Reference — our engine
| DRG | 871 · w/ MCC |
|---|---|
| IPPS allowed | $23,056.52 |
| Grouper | v43.1 |
Vendor — NetworX Pricer
| Contract | MOCK-IP-2026 |
|---|---|
| Allowed amount | $21,903.69 |
| Methodology | DRG · 95% of IPPS |
Bearer-authed POST over the connector framework; the vendor's reply is normalized alongside our reference. Point the URL at your tenant and it goes live — no code change.
Honest by design
Within 0.01% of CMS — and it tells you where it isn't.
The whole point is trust, so nothing is guessed. Where a case needs logic we haven't modeled yet, the tool flags it rather than inventing a number.
- Known gap
The self-contained grouper doesn't yet read ventilator hours, so code-driven grouping tops out at DRG 189 instead of 207/208 — though pricing of 208 already matches CMS to $0.33 via DRG-in. Everything flagged, nothing faked.
Independent estimator built on real IPPS reference data (FY2027, CMS-1849-F; FY2026, CMS-1833-F, for earlier discharges) and the CMS MS-DRG tables, v39 to v44. Not affiliated with or endorsed by CMS or any payer/vendor; product names shown for integration reference only. Estimates are verified against CMS but are not a substitute for official adjudication.