R9-22-712.09. Hierarchy for Tier Assignment through September 30, 2014

ALLOWED SPLITS MATERNITY A primary diagnosis defined as maternity 640.xx - 643.xx, 644.2x - 676.xx, v22.xx - v24.xx or v27.xx. IDENTIFICATION CRITERIA TIER None NICU Revenue Code of 174 and the provider has a Level II or Level III NICU. Nursery ICU Revenue Codes of 200-204, 207- 212, or 219. Surgery Psychiatric Routine SURGERY Surgery is identified by a revenue code of 36x. To qualify in this tier, there must be a valid surgical procedure code that is not on the excluded procedure list. ICU PSYCHIATRIC Psychiatric Revenue Codes of ICU 114, 124, 134, 144, or 154 AND primary Psychiatric Diagnosis = 290.xx - 316.xx. If a routine revenue code is present and all diagnoses codes on the claim are equal to 290.xx - 316.xx, classify as a psychiatric claim. NURSERY Revenue Code of 17x, not equal to 174. NICU ROUTINE Revenue Codes of 100 - 101, 110- 113, 116 - 123, 126 - 133, 136 - 143, 146 - 153, 156 - 159, 16x, 206, 213, or 214. ICU