DRG List - Tufts Health Plan

DRG List
The following payment policy applies to Tufts Health Plan ® inpatient hospitals that are reimbursed based
on Diagnostic Related Grouping methodology. This list does not apply to skilled nursing facilities (SNF)
or transitional care units (TCU).
Tufts Health Plan incorporates the Diagnostic Related Grouping (DRG) methodology, devised by Centers
for Medicare & Medicaid Services (CMS), to price inpatient claims. The DRG type assigned to the DRG
code determines whether an inpatient hospital claim will be reimbursed as a medical or surgical claim. For
additional information regarding DRG, reference the Inpatient Payment Policy.
AP-DRG All Patient Diagnosis Related Groups Definition Manual, version 14.0
DRG Description DRG Type
1 Craniotomy Age >17 Except for Trauma Surgical
2 Craniotomy for Trauma Age >17 Surgical
4 Spinal Procedures Surgical
5 Extracranial Vascular Procedures Surgical
6 Carpal Tunnel Release Surgical
7 Periph,Cran Nerv/Oth Nerv Sys Proc w CC Surgical
8 Periph,Cran Nerv/Oth Nerv Sys Proc w/o CC Surgical
9 Spinal Disorders & Injuries Surgical
10 Nervous System Neoplasms w CC Medical
11 Nervous System Neoplasms w/o CC Medical
12 Degenerative Nervous System Disorders Medical
13 Multiple Sclerosis & Cerebellar Ataxia Medical
14 Specific Cerebrovasc Disorders Exc Tia Medical
15 Trans Ischem Attack & Precereb Occlusion Medical
16 Nonspecific Cerebrovasc Disorders w CC Medical
17 Nonspecific Cerebrovasc Disorders w/o CC Medical
18 Cranial & Periph Nerve Disorders w CC Medical
19 Cranial & Periph Nerve Disorders w/o CC Medical
20 Nerv Syst Infect Exc Viral Meningitis Medical
21 Viral Meningitis Medical
22 Hypertensive Encephalopathy Medical
23 Nontraumatic Stupor & Coma Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 1 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
24 Seizure & Headache Age >17 w CC Medical
25 Seizure & Headache Age >17 w/o CC Medical
34 Other Disorders Of Nervous System w CC Medical
35 Other Disorders Of Nervous System w/o CC Medical
36 Retinal Procedures Surgical
37 Orbital Procedures Surgical
38 Primary Iris Procedures Surgical
39 Lens Procedures with or w/o Vitrectomy Surgical
40 Extraocular Proc Exc Orbit Age >17 Surgical
41 Extraocular Proc Exc Orbit Age 0-17 Surgical
42 Intraocular Proc Exc Retina, Iris & Lens Surgical
43 Hyphema Medical
44 Acute Major Eye Infections Medical
45 Neurological Eye Disorders Medical
46 Oth Disorders of the Eye Age >17 w CC Medical
47 Oth Disorders of the Eye Age >17 w/o CC Medical
48 Oth Disorders of the Eye Age 0-17 Medical
49 Major Head & Neck Proc Ex for Malignancy Surgical
50 Sialoadenectomy Surgical
51 Salivary Gland Proc Exc Sialoadenectomy Surgical
52 Cleft Lip & Palate Repair Surgical
53 Sinus & Mastoid Procedures Age >17 Surgical
54 Sinus & Mastoid Procedures Age 0-17 Surgical
55 Misc Ear, Nose, Mouth & Throat Procedures Surgical
56 Rhinoplasty Surgical
57 T&A Proc Ex Tonslct/Adndct Only Age >17 Surgical
58 T&A Proc Ex Tonslct/Adndct Only Age 0-17 Surgical
59 Tonsillect &/Or Adenoidect Only Age >17 Surgical
60 Tonsillect &/Or Adenoidect Only Age 0-17 Surgical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 2 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
61 Myringotomy w Tube Insertion Age >17 Surgical
62 Myringotomy w Tube Insertion Age 0-17 Surgical
63 Other Ear, Nose, Mouth & Throat O.R. Procs Surgical
64 Ear, Nose, Mouth & Throat Malignancy Medical
65 Dysequilibrium Medical
66 Epistaxis Medical
67 Epiglottitis Medical
68 Otitis Media & Uri Age >17 w CC Medical
69 Otitis Media & Uri Age >17 w/o CC Medical
70 Otitis Media & Uri Age 0-17 Medical
71 Laryngotracheitis Medical
72 Nasal Trauma & Deformity Medical
73 Oth Ear, Nose, Mouth & Throat Dx Age >17 Medical
74 Oth Ear, Nose, Mouth & Throat Dx Age 0-17 Medical
75 Major Chest Procedures Surgical
76 Other Resp System O.R. Procedures w CC Surgical
77 Other Resp System O.R. Procedures w/o CC Surgical
78 Pulmonary Embolism Medical
79 Resp Infect & Inflam Age >17 w CC Medical
80 Resp Infect & Inflam Age >17 w/o CC Medical
82 Respiratory Neoplasms Medical
83 Major Chest Trauma w CC Medical
84 Major Chest Trauma w/o CC Medical
85 Pleural Effusion w CC Medical
86 Pleural Effusion w/o CC Medical
87 Pulmonary Edema & Respiratory Failure Medical
88 Chronic Obstructive Pulmonary Disease Medical
89 Simple Pneumonia, Pleurisy Age >17 w CC Medical
90 Simple Pneumonia, Pleurisy Age >17 w/o CC Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 3 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
92 Interstitial Lung Disease w CC Medical
93 Interstitial Lung Disease w/o CC Medical
94 Pneumothorax w CC Medical
95 Pneumothorax w/o CC Medical
96 Bronchitis & Asthma Age >17 w CC Medical
97 Bronchitis & Asthma Age >17 w/o CC Medical
99 Respiratory Signs & Symptoms w CC Medical
100 Respiratory Signs & Symptoms w/o CC Medical
101 Other Resp System Diagnoses w CC Medical
102 Other Resp System Diagnoses w/o CC Medical
103 Heart Transplant Surgical
104 Cardiac Valve Proc w Cardiac Cath Surgical
105 Cardiac Valve Proc w/o Cardiac Cath Surgical
106 Coronary Bypass w Cardiac Cath Surgical
107 Coronary Bypass w/o Cardiac Cath Surgical
108 Other Cardiothoracic Procedures Surgical
110 Major Cardiovascular Procedures w CC Surgical
111 Major Cardiovascular Procedures w/o CC Surgical
112 Percutaneous Cardiovascular Procedures Surgical
113 Amput for Circ Disor Exc Uppr Limb & Toe Surgical
114 Uppr Limb & Toe Amput for Circ Disor Surgical
115 Perm Pacemkr Impl w Ami, Heart Fail, Shck Surgical
116 Perm Pacemkr Impl w/o Ami, Heart Fail, Shck Surgical
117 Card Pacemkr Revision Exc Device Replace Surgical
118 Cardiac Pacemaker Device Replacement Surgical
119 Vein Ligation & Stripping Surgical
120 Other Circulatory System O.R. Procedures Surgical
121 Circ Disor w Ami & Cv Comp Disch Alive Medical
122 Circ Disor w Ami w/o Cv Comp Disch Alive Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 4 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
123 Circ Disor w Ami, Expired Medical
124 Circ Dis Ex Ami w Card Cath & Complx Dx Medical
125 Circ Dis Ex Ami w Card Cath Wo Complx Dx Medical
126 Acute & Subacute Endocarditis Medical
127 Heart Failure & Shock Medical
128 Deep Vein Thrombophlebitis Medical
129 Cardiac Arrest, Unexplained Medical
130 Peripheral Vascular Disorders w CC Medical
131 Peripheral Vascular Disorders w/o CC Medical
132 Atherosclerosis w CC Medical
133 Atherosclerosis w/o CC Medical
134 Hypertension Medical
135 Card Congen & Valv Disor Age >17 w CC Medical
136 Card Congen & Valv Disor Age >17 w/o CC Medical
137 Card Congen & Valv Disor Age 0-17 Medical
138 Card Arrhythmia & Conductn Disor w CC Medical
139 Card Arrhythmia & Conductn Disor w/o CC Medical
140 Angina Pectoris Medical
141 Syncope & Collapse w CC Medical
142 Syncope & Collapse w/o CC Medical
143 Chest Pain Medical
144 Oth Circulatory System Diagnoses w CC Medical
145 Oth Circulatory System Diagnoses w/o CC Medical
146 Rectal Resection w CC Surgical
147 Rectal Resection w/o CC Surgical
148 Major Small & Large Bowel Proc w CC Surgical
149 Major Small & Large Bowel Proc w/o CC Surgical
150 Peritoneal Adhesiolysis w CC Surgical
151 Peritoneal Adhesiolysis w/o CC Surgical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 5 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
152 Minor Small & Large Bowel Proc w CC Surgical
153 Minor Small & Large Bowel Proc w/o CC Surgical
154 Stomach, Esoph & Duod Proc Age >17 w CC Surgical
155 Stomach, Esoph & Duod Proc Age >17 w/o CC Surgical
156 Stomach, Esoph & Duod Proc Age 0-17 Surgical
157 Anal & Stomal Procedures w CC Surgical
158 Anal & Stomal Procedures w/o CC Surgical
159 Hernia Proc Exc Ing, Femor Age >17 w CC Surgical
160 Hernia Proc Exc Ing, Femor Age >17 w/o CC Surgical
161 Ing & Femoral Hernia Proc Age >17 w CC Surgical
162 Ing & Femoral Hernia Proc Age >17 w/o CC Surgical
163 Hernia Procedures Age 0-17 Surgical
164 Appendectomy w Complic Princ Dx w CC Surgical
165 Appendectomy w Complic Princ Dx w/o CC Surgical
166 Appendectomy w/o Complic Princ Dx w CC Surgical
167 Appendectomy w/o Complic Princ Dx w/o CC Surgical
168 Mouth Procedures w CC Surgical
169 Mouth Procedures w/o CC Surgical
170 Other Digestive System O.R. Proc w CC Surgical
171 Other Digestive System O.R. Proc w/o CC Surgical
172 Digestive Malignancy w CC Medical
173 Digestive Malignancy w/o CC Medical
174 G.I. Hemorrhage w CC Medical
175 G.I. Hemorrhage w/o CC Medical
176 Complicated Peptic Ulcer Medical
177 Uncomplicated Peptic Ulcer w CC Medical
178 Uncomplicated Peptic Ulcer w/o CC Medical
179 Inflammatory Bowel Disease Medical
180 G.I. Obstruction w CC Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 6 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
181 G.I. Obstruction w/o CC Medical
182 Esphgitis, Ge, Misc Dig Dis Age >17 w CC Medical
183 Esphgitis, Ge, Misc Dig Dis Age >17 w/o CC Medical
185 Dent, Oral Dis Ex Extract, Restor Age >17 Medical
186 Dent, Oral Dis Ex Extract, Restor Age 0-17 Medical
187 Dental Extractions & Restorations Medical
188 Other Digestive System Dx Age >17 w CC Medical
189 Other Digestive System Dx Age >17 w/o CC Medical
191 Pancreas, Liver & Shunt Procedures w CC Surgical
192 Pancreas, Liver & Shunt Procedures w/o CC Surgical
193 Bil Proc w CC Ex Only Cholcyst W, Wo Cd Surgical
194 Bil Proc w/o CC Ex Only Cholcyst W, Wo Cde Surgical
195 Cholecystectomy W C.D.E. w CC Surgical
196 Cholecystectomy W C.D.E. w/o CC Surgical
197 Cholecystectomy w/o C.D.E. w CC Surgical
198 Cholecystectomy w/o C.D.E. w/o CC Surgical
199 Hepatobil Diagnostic Proc for Malignancy Surgical
200 Hepatobil Diagnostic Proc for Non-Malig Surgical
201 Other Hepatobil or Pancreas O.R. Proc Surgical
202 Cirrhosis & Alcoholic Hepatitis Medical
203 Malignancy of Hepatobil Syst or Pancreas Medical
204 Disorders of Pancreas Except Malignancy Medical
205 Disor Liver Ex Malig, Cirr, Alc Hepa w CC Medical
206 Disor Liver Ex Malig, Cirr, Alc Hepa w/o CC Medical
207 Disorders of he Biliary Tract w CC Medical
208 Disorders of the Biliary Tract w/o CC Medical
209 Maj Jnt/Limb Reatt Proc, Lw Ext w/o Infect Surgical
210 Hip, Femur Proc Ex Maj Jnt Age >17 w CC Surgical
211 Hip, Femur Proc Ex Maj Jnt Age >17 w/o CC Surgical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 7 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
212 Hip, Femur Proc Ex Maj Jnt Age 0-17 Surgical
213 Amput for Muscskl Syst & Conn Tiss Disor Surgical
216 Biopsies of Muscskl Syst & Conn Tissue Surgical
217 Wnd Dbrd & Skn Grft Ex Hand, Ex Open Wnd Surgical
218 Lw Ext, Hum Proc Ex Hip, Ft, Fem >17 w CC Surgical
219 Lw Ext, Hum Proc Ex Hip, Ft, Fem >17 w/o CC Surgical
220 Lw Ext,Hum Proc Ex Hip, Ft, Fem 0-17 Surgical
221 Knee Procedures w CC Surgical
222 Knee Procedures w/o CC Surgical
223 Maj Shldr/Elbow,Oth Uppr Extr Proc w CC Surgical
224 Shldr, Elbw, forearm Proc, Ex Maj Jnt w/o CC Surgical
225 Foot Procedures Surgical
226 Soft Tissue Procedures w CC Surgical
227 Soft Tissue Procedures w/o CC Surgical
228 Maj Thumb, Jnt, Oth Hand, Wrist Proc w CC Surgical
229 Hand, Wrist Proc Exc Maj Jnt Proc w/o CC Surgical
230 Loc Excis, Remov Int Fix Dev Hip, Femur Surgical
231 Loc Excis, Remov Int Fix Dev Ex Hip, Femur Surgical
232 Arthroscopy Surgical
233 Oth Muscskl & Conn Tiss O.R. Proc w CC Surgical
234 Oth Muscskl & Conn Tiss O.R. Proc w/o CC Surgical
235 Fractures of Femur Medical
236 Fractures of Hip & Pelvis Medical
237 Sprain, Strain, Disloc of Hip, Pelvis, Thigh Medical
238 Osteomyelitis Medical
239 Path Fract & Muscskl, Con Tiss Malignancy Medical
240 Connective Tissue Disorders w CC Medical
241 Connective Tissue Disorders w/o CC Medical
242 Septic Arthritis Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 8 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
243 Medical Back Problems Medical
244 Bone Diseases, Spec Arthropathies w CC Medical
245 Bone Diseases, Spec Arthropathies w/o CC Medical
246 Non-Specific Arthropathies Medical
247 Signs & Symptoms, Muscskl Syst, Conn Tiss Medical
248 Tendonitis, Myositis & Bursitis Medical
249 Aftercare, Muscskl Syst & Conn Tissue Medical
250 Fx,Spr,Str,Dsl Frarm,Hand,Ft >17 w CC Medical
251 Fx,Spr,Str,Dsl Frarm,Hand,Ft >17 w/o CC Medical
252 Fx,Spr,Str,Dsl Frarm,Hand,Ft 0-17 Medical
253 Fx,Spr,Str,Dsl Uarm,Lwlg Ex Ft >17 w CC Medical
254 Fx,Spr,Str,Dsl Uarm,Lwlg Ex Ft >17 w/o CC Medical
255 Fx,Spr,Str,Dsl Uarm,Lwlg Ex Ft 0-17 Medical
256 Other Muscskl Syst & Conn Tiss Diagnoses Medical
257 Total Mastectomy for Malignancy w CC Surgical
258 Total Mastectomy for Malignancy w/o CC Surgical
259 Subtot Mastectomy for Malignancy w CC Surgical
260 Subtot Mastectomy for Malignancy w/o CC Surgical
261 Breast Proc Non-Malig Ex Biop, Loc Excis Surgical
262 Breast Biopsy & Loc Excis for Non-Malig Surgical
263 Skn Grft, Debrid Skn Ulcr, Cellulit w CC Surgical
264 Skn Grft, Debrid Skn Ulcr, Cellulit w/o CC Surgical
265 Skn Grft, Debrid Ex Skn Ulcr, Cellul w CC Surgical
266 Skn Grft, Debrid Ex Skn Ulcr, Cellul w/o CC Surgical
267 Perianal & Pilonidal Procedures Surgical
268 Skin, Subcut Tissue, Breast Plastic Proc Surgical
269 Oth Skin, Subcut Tiss, Breast Proc w CC Surgical
270 Oth Skin, Subcut Tiss, Breast Proc w/o CC Surgical
271 Skin Ulcers Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 9 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
272 Major Skin Disorders w CC Medical
273 Major Skin Disorders w/o CC Medical
274 Malignant Breast Disorders w CC Medical
275 Malignant Breast Disorders w/o CC Medical
276 Non-Malignant Breast Disorders Medical
277 Cellulitis Age >17 w CC Medical
278 Cellulitis Age >17 w/o CC Medical
279 Cellulitis Age 0-17 Medical
280 Trauma Skn, Subcut Tis, Breast Age>17 w CC Medical
281 Trauma Skn, Subcu Tis, Breast Age>17 w/o CC Medical
282 Trauma Skn, Subcut Tiss, Breast Age 0-17 Medical
283 Minor Skin Disorders w CC Medical
284 Minor Skin Disorders w/o CC Medical
285 Amput Lowr Limb Endocr, Nutr, Metab Disor Surgical
286 Adrenal & Pituitary Procedures Surgical
287 Skn Grft, Wnd Dbrd Endoc,Nutr, Metab Disor Surgical
288 O.R. Procedures for Obesity Surgical
289 Parathyroid Procedures Surgical
290 Thyroid Procedures Surgical
291 Thyroglossal Procedures Surgical
292 Oth Endocr, Nutrit, Metab O.R. Proc w CC Surgical
293 Oth Endocr, Nutrit, Metab O.R. Proc w/o CC Surgical
294 Diabetes Age >35 Medical
295 Diabetes Age 0-35 Medical
296 Nutrit & Misc Metab Disor Age >17 w CC Medical
297 Nutrit & Misc Metab Disor Age >17 w/o CC Medical
298 Nutrit & Misc Metab Disor Age 0-17 Medical
299 Inborn Errors of Metabolism Medical
300 Endocrine Disorders w CC Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 10 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
301 Endocrine Disorders w/o CC Medical
302 Kidney Transplant Surgical
303 Kidney, Uretr, Maj Bladdr Proc for Neopl Surgical
304 Kidny, Uretr, Maj Bladdr Proc Nonneo w CC Surgical
305 Kidny, Uretr, Maj Bladdr Proc Nonneo w/o CC Surgical
306 Prostatectomy w CC Surgical
307 Prostatectomy w/o CC Surgical
308 Minor Bladder Procedures w CC Surgical
309 Minor Bladder Procedures w/o CC Surgical
310 Transurethral Procedures w CC Surgical
311 Transurethral Procedures w/o CC Surgical
312 Urethral Procedures, Age >17 w CC Surgical
313 Urethral Procedures, Age >17 w/o CC Surgical
314 Urethral Procedures, Age 0-17 Surgical
315 Other Kidney & Urinary Tract O.R. Proc Surgical
316 Renal Failure Medical
317 Admit for Renal Dialysis Medical
318 Kidney & Urinary Tract Neoplasms w CC Medical
319 Kidney & Urinary Tract Neoplasms w/o CC Medical
320 Kidney,Urin Tract Infect Age >17 w CC Medical
321 Kidney,Urin Tract Infect Age >17 w/o CC Medical
322 Kidney,Urin Tract Infect Age 0-17 Medical
323 Urinary Stones w CC, &/Or Esw Lithotripsy Medical
324 Urinary Stones w/o CC Medical
325 Kidny, Urin Tract Sign, Symp Age >17 w CC Medical
326 Kidny, Urin Tract Sign, Symp Age >17 w/o CC Medical
327 Kidny, Urin Tract Sign, Symp Age 0-17 Medical
328 Urethral Stricture Age >17 w CC Medical
329 Urethral Stricture Age >17 w/o CC Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 11 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
330 Urethral Stricture Age 0-17 Medical
331 Oth Kidney & Urin Tract Dx Age >17 w CC Medical
332 Oth Kidney & Urin Tract Dx Age >17 w/o CC Medical
333 Oth Kidney & Urin Tract Dx Age 0-17 Medical
334 Major Male Pelvic Procedures w CC Surgical
335 Major Male Pelvic Procedures w/o CC Surgical
336 Transurethral Prostatectomy w CC Surgical
337 Transurethral Prostatectomy w/o CC Surgical
338 Testes Procedures, for Malignancy Surgical
339 Testes Procedures, Non-Malig Age >17 Surgical
340 Testes Procedures, Non-Malig Age 0-17 Surgical
341 Penis Procedures Surgical
342 Circumcision Age >17 Surgical
343 Circumcision Age 0-17 Surgical
344 Oth Male Repro Syst O.R. Proc for Malig Surgical
345 Oth Male Repro Syst O.R. Proc Ex Malig Surgical
346 Malignancy, Male Repro System, w CC Medical
347 Malignancy, Male Repro System, w/o CC Medical
348 Benign Prostatic Hypertrophy w CC Medical
349 Benign Prostatic Hypertrophy w/o CC Medical
350 Inflammation Of The Male Repro System Medical
351 Sterilization, Male Medical
352 Other Male Reproductive System Diagnoses Medical
353 Pelvic Evisc,Rad Hysterect & Rad Vulvect Surgical
354 Uter, Adnex Proc Non-Ov/Adnex Malig w CC Surgical
355 Uter, Adnex Proc Non-Ov/Adnex Malig w/o CC Surgical
356 Female Repro System Reconstructive Proc Surgical
357 Uter, Adnex Proc for Ovar, Adnexal Malig Surgical
358 Uter, Adnex Pr, Ca In Situ/Non-Malig w CC Surgical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 12 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
359 Uter, Adnex Pr, Ca In Situ/Non-Malig w/o CC Surgical
360 Vagina, Cervix & Vulva Procedures Surgical
361 Laparoscopy, Incisional Tubal Interrupt Surgical
362 Endoscopic Tubal Interruption Surgical
363 D&C, Conization, Radio-Implant, for Malig Surgical
364 D&C, Conization Except for Malignancy Surgical
365 Other Female Repro System O.R. Proc Surgical
366 Malignancy, Female Repro System w CC Medical
367 Malignancy, Female Repro System w/o CC Medical
368 Infections, Female Repro System Medical
369 Menstrual,Other Female Repro Syst Disor Medical
370 Cesarean Section w CC Surg-Ob
371 Cesarean Section w/o CC Surg-Ob
372 Vaginal Delivery W Complic Diagnoses Medi-Ob
373 Vaginal Delivery w/o Complic Diagnoses Medi-Ob
374 Vaginal Delivery W Steril &/Or D&C Surg-Ob
375 Vagin Deliv W O.R Proc Ex Steril &Or D&C Surg-Ob
376 Postpart & Post Abort Dx w/o O.R. Proc Medical
377 Postpart & Post Abort Dx w O.R. Proc Surgical
378 Ectopic Pregnancy Medical
379 Threatened Abortion Medical
380 Abortion w/o D&C Medical
381 Abortion w D&C, Aspir Curett,Hysterotomy Surgical
382 False Labor Medical
383 Oth Antepartum Dx w Med Complications Medical
384 Oth Antepartum Dx w/o Med Complications Medical
392 Splenectomy Age >17 Surgical
393 Splenectomy Age 0-17 Surgical
394 Oth O.R Proc of Blood, Blood form Organs Surgical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 13 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
395 Red Blood Cell Disorders Age >17 Medical
397 Coagulation Disorders Medical
398 Reticuloendothelial & Immun Disor w CC Medical
399 Reticuloendothelial & Immun Disor w/o CC Medical
400 Lymphoma & Leukemia W Major O.R. Proc Surgical
401 Lymphoma, Nonacu Leuk Oth O.R Proc w CC Surgical
402 Lymphoma, Nonacu Leuk Oth O.R Proc w/o CC Surgical
403 Lymphoma, Non-Acute Leukemia w CC Medical
404 Lymphoma, Non-Acute Leukemia w/o CC Medical
406 Myel Dis, Prly Dif Neo Maj O.R. Proc w CC Surgical
407 Myel Dis, Prly Dif Neo Maj O.R. Proc w/o CC Surgical
408 Myel Dis, Prly Dif Neo Oth O.R. Proc Surgical
409 Radiotherapy Medical
410 Chemotherapy Medical
411 History of Malignancy w/o Endoscopy Medical
412 History of Malignancy W Endoscopy Medical
413 Oth Myel Dis,Poorly Diff Neopl Dx w CC Medical
414 Oth Myel Dis,Poorly Diff Neopl Dx w/o CC Medical
415 O.R. Proc for Infectious & Parasitic Dis Surgical
416 Septicemia Age >17 Medical
417 Septicemia Age 0-17 Medical
418 Postoperative & Post-Traumatic Infection Medical
419 Fever of Unknown Origin Age >17 w CC Medical
420 Fever of Unknown Origin Age >17 w/o CC Medical
421 Viral Illness Age >17 Medical
422 Viral Ill,Fever of Unknwn Orig Age 0-17 Medical
423 Oth Infectious & Parasitic Dis Diagnoses Medical
424 O.R Proc W Princ Dx of Mental Illness Surgical
425 Acu Adj React, Disturb Psychosoc Dysfunct Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 14 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
426 Depressive Neuroses Medical
427 Neuroses Except Depressive Medical
428 Disorders of Personality, Impulse Control Medical
429 Organic Disturbances, Mental Retardation Medical
430 Psychoses Medical
431 Childhood Mental Disorders Medical
432 Other Mental Disorder Diagnoses Medical
439 Skin Grafts for Injuries Surgical
440 Wound Debridement, Injuries Ex Open Wound Surgical
441 Hand Procedures for Injuries Surgical
442 Other O.R Procedures for Injuries w CC Surgical
443 Other O.R Procedures for Injuries w/o CC Surgical
444 Traumatic Injury Age >17 w CC Medical
445 Traumatic Injury Age >17 w/o CC Medical
446 Traumatic Injury Age 0-17 Medical
447 Allergic Reactions Age >17 Medical
448 Allergic Reactions Age 0-17 Medical
449 Poison, Toxic Effects Drugs Age >17 w CC Medical
450 Poison, Toxic Effects Drugs Age >17 w/o CC Medical
451 Poison, Toxic Effects Drugs Age 0-17 Medical
452 Complications of Treatment w CC Medical
453 Complications of Treatment w/o CC Medical
454 Oth Injury, Poison, Toxic Effect Dx w CC Medical
455 Oth Injury, Poison, Toxic Effect Dx w/o CC Medical
456 Burns, Trans To Another Acute Care Facil Surgical
457 Extensive Burns w/o O.R. Procedure Medical
458 Non-Extensive Burns w Skin Graft Surgical
459 Non-Ext Burns w Wnd Debrid, Oth O.R Proc Surgical
460 Non-Extensive Burns w/o O.R. Procedure Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 15 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
461 O.R Proc w Dx Oth Contact W Health Serv Surgical
462 Rehabilitation Medical
463 Signs & Symptoms w CC Medical
464 Signs & Symptoms w/o CC Medical
465 Aftercare w Hist Malig As Secondary Dx Medical
466 Aftercare w/o Hist Malig As Secondary Dx Medical
467 Other Factors Influencing Health Status Medical
468 Extens O.R. Proc Unrelated to Princ Dx Surgical
469 Princ Dx Invalid as Discharge Diagnosis Invalid
470 Ungroupable Ungroupable
471 Bilat, Mult Maj Joint Proc of Low Extrem Surgical
472 Extensive Burns w O.R. Procedure Surgical
475 Resp System Dx with Ventilator Support Medical
476 Prostatic O.R Proc Unrelated to Princ Dx Surgical
477 Non-Exten O.R Proc Unrelated to Princ Dx Surgical
478 Other Vascular Procedures w CC Surgical
479 Other Vascular Procedures w/o CC Surgical
480 Liver Transplant Surgical
482 Trach W Mouth, Larynx or Pharynx Disorder Surgical
483 Trach Exc Mouth, Larynx, Pharynx Disorder Surgical
491 Major Joint & Limb Proc Upper Extremity Surgical
493 Laparoscopic Cholecytectomy w/o Cde w CC Surgical
494 Laparoscopic Cholecytectomy w/o Cde w CC Surgical
530 Craniotomy with Major CC Surgical
531 Nervous Sys Procs Exc Craniotomy w MCC Surgical
532 Tia, Precereb Occlusn, Seiz, Headache w
MCCC
Medical
533 Oth Nerv Sys Dis Exc Tia, Seiz, Head w MCC Medical
534 Eye Procedures With Major CC Surgical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 16 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
535 Eye Disorders With Major CC Medical
536 Ent & Mouth Procs Ex Maj Head, Neck w MCC Surgical
538 Major Chest Procedures With Major CC Surgical
539 Respiratory Procs Exc Major Chest w MCC Surgical
540 Respiratory Infection,Inflammation w MCC Medical
541 Resp Dis Exc Infect, Bronch, Asthma w MCC Medical
542 Bronchitis & Asthma With Major CC Medical
543 Circ Dis Ex Ami, Endocard, Chf, Arrhy w MCC Medical
544 Chf & Cardiac Arrhythmia with Major CC Medical
545 Cardiac Valve Procedure with Major CC Surgical
546 Coronary Bypass with Major CC Surgical
547 Other Cardiothoracic Procs w Major CC Surgical
548 Card Pacemaker Implant Or Revision w MCC Surgical
549 Major Cardiovascular Procedures w Maj CC Surgical
550 Other Vascular Procedures w Major CC Surgical
551 Esoph, Gastroent, Uncomp Ulcers w Major CC Medical
552 Digest Dis Ex Esop, Gastr, Unc Ulcer w MCC Medical
553 Digest Proc Ex Hern, Maj Stom/Bowel w MCC Surgical
554 Hernia Procedures with Major CC Surgical
555 Pancr, Liv, Ot Bil Trct Ex Liv Trans w MCC Surgical
556 Cholecystectomy, Oth Hepatobil Proc w MCC Surgical
557 Hepatobiliary & Pancreas Disorder w MCC Medical
558 Maj Muscsk Proc Ex Bil,Mul Maj Jnt w MCC Surgical
559 Non-Major Musculoskeletal Procs w Maj CC Surgical
560 Musc Dis Ex Osteo, Sep Arth, Con Tis w MCC Medical
561 Osteomy, Septic Arth, Conn Tiss Dis w MCC Medical
562 Major Skin & Breast Disorders w Major CC Medical
563 Other Skin Disorders with Major CC Medical
564 Skin & Breast Procedures with Major CC Surgical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 17 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
565 Endo, Nutr, Metb Pro Ex Low Limb w Amp,
MCC
Surgical
566 Endo, Nutr, Metab Dis Exc Eat Dis,Cf w MCC Medical
567 Kidney, Urin Trct Proc Ex Kid Trans w MCC Surgical
568 Renal Failure with Major CC Medical
569 Kidney, Urin Trct Dis Ex Renal Fail w MCC Medical
570 Male Reproductive Disorders w Major CC Medical
571 Male Reproductive Procedures w Major CC Surgical
572 Female Reproductive Disorders w Major CC Medical
573 Non-Radical Female Reproductv Proc w MCC Surgical
574 Blood,Blood form Org & Immunol Dis w MCC Medical
575 Blood,Blood form Org & Immuno Proc w MCC Surgical
576 Acute Leukemia with Major CC Medical
577 Myeloprol Dis, Poorly Diff Neoplasm w MCC Medical
578 Lymphoma, Non-Acute Leukemia w Major CC Medical
579 Procs for Lymph, Leuk, Myeloprol Dis w MCC Surgical
580 System Infec, Parasit Dis Ex Septic w MCC Medical
581 Systemic Infect, Parasitic Dis Proc w MCC Surgical
582 Injuries Exc Multiple Trauma w Major CC Medical
583 Procs for Injuries Exc Mult Trauma w MCC Surgical
584 Septicemia w Major CC Medical
585 Maj Stom, Esoph, Duod,Bowel Proc w Maj CC Surgical
586 Ent & Mouth Disorders Age

DRG Description DRG Type
607 Bwt 1000-1499g w/o Sig or Pr Dchg Alive Medical
608 Neonate, Birthwt 1000-1499g, Died Medical
609 Bwt 1500-1999g Sig or Pr w Mult Maj Prob Surgical
610 Bwt 1500-1999g w Sig or Pr w/o M Maj Pro Surgical
611 Bwt 1500-1999g w/o Sig or Pr w M Maj Pro Medical
612 Bwt 1500-1999g w/o Sig or Pr W Maj Prob Medical
613 Bwt 1500-1999g w/o Sig or Pr W Min Prob Medical
614 Bwt 1500-1999g w/o Sig or Pr W Oth Prob Medical
615 Bwt 2000-2499g Sig or Pr w Mult Maj Prob Surgical
616 Bwt 2000-2499g w Sig or Pr w/o M Maj Pro Surgical
617 Bwt 2000-2499g w/o Sig or Pr W M Maj Pro Medical
618 Bwt 2000-2499g w/o Sig or Pr W Maj Prob Medical
619 Bwt 2000-2499g w/o Sig or Pr W Min Prob Medical
620 Bwt 2000-2499g w/o Sig or Pr,Norm Nb Dx Medical
621 Bwt 2000-2499g w/o Sig or Pr w Oth Prob Medical
622 Bwt>2499g w Sig or Pr W Mult Maj Prob Surgical
623 Bwt>2499g w Sig or Pr w/o Mult Maj Prob Surgical
624 Bwt>2499g w Minor Abdominal Procedure Surgical
626 Bwt>2499g w/o Sig or Pr w Mult Maj Prob Medical
627 Bwt>2499g w/o Sig or Pr w Maj Prob Medical
628 Bwt>2499g w/o Sig or Pr w Min Prob Medical
629 Bwt>2499g w/o Sig or Pr w Norm Newbrn Dx Medical
630 Bwt>2499g w/o Sig or Pr w Oth Prob Medical
631 Bpd & Oth Chronic Resp Dis Perinatal Per Medical
633 Mult Oth & Unspec Congen Anomalies w CC Medical
634 Mult Oth & Unspec Congen Anomalies w/o CC Medical
635 Neonatal Aftercare for Weight Gain Medical
636 Infant Aftercre Wt Gain,Age >28days

DRG Description DRG Type
638 Neonate, Died w/I 1day Brth,Not Born Here Medical
639 Neonate, Transferrd 12 Medical
703 HiIVw/or Procedure w/Major Related Dx Surgical
704 HIV Related Malig w Opioid Use Age>12 Medical
705 HiV Related Malig w/o Opioid Use Age>12 Medical
706 HIV w/Multiple Major Related Dx Medical
707 HIV Related Infec w Opioid Use Age>12 Medical
708 HIV Related Infec w/o Opioid Use Age>12 Medical
709 HIV w/Major Related w/Multi Major W/Tb Medical
710 HIV w Oth Relat Cond w Opioid Use Age>12 Medical
711 HIV w Oth Rel Cond w/o Opioid Use Age>12 Medical
712 HIV w/o Spec Related Condition Age12 Medical
714 HIV w/o Spec Rel Cond w/o Op Use Age>12 Medical
715 HIV w/other Related Diagnosis Medical
716 HIV w/o Other Related Diagnosis Medical
730 Craniotomy, Multiple Significant Trauma Surgical
731 Spine, Hip, Femur, Lmb Proc, Mult Sig Trauma Surgical
732 Other O.R. Procedure, Mult Sig Trauma Surgical
733 Head, Chest, Low Limb Dx, Mult Sig Trauma Medical
734 Other Dx, Multiple Significant Trauma Medical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 20 of 23 Tufts Health Plan – DRG List

DRG Description DRG Type
737 Ventricular Shunt Revision, Age < 18 Surgical
738 Craniotomy Age < 18 w CC Surgical
739 Craniotomy Age < 18 w/o CC Surgical
740 Cystic Fibrosis Medical
743 Opioid Abuse/Dependence, Left Ama Medical
744 Opioid Abuse/Dependence w CC Medical
745 Opioid Abuse/Dependence w/o CC Medical
746 Cocaine Abuse/Dependence, Left Ama Medical
747 Cocaine Abuse/Dependence w CC Medical
748 Cocaine Abuse/Dependence w/o CC Medical
749 Alcohol Abuse/Dependence, Left Ama Medical
750 Alcohol Abuse/Dependence w CC Medical
751 Alcohol Abuse/Dependence w/o CC Medical
752 Lead Poisoning Medical
753 Compulsive Nutrition Disorder Rehab Medical
754 Tertiary Aftercare, Age => 1 Year Medical
755 Spinal Fusion with CC Surgical
756 Spinal Fusion without CC Surgical
757 Back & Neck Proc Exc Spinal Fusion w CC Surgical
758 Back & Neck Proc Ex Spinal Fusion w/o CC Surgical
759 Multiple Channel Cochlear Implants Surgical
760 Hemophilia Factors VIII and IX Medical
761 Traumatic Stupor & Coma, Coma > 1 Hr Medical
762 Conc, Intcran Inj, Coma

DRG Description DRG Type
767 Traum Stupor & Coma 17 w/o CC Medical
768 Seizure & Headache Age 0-17 w CC Medical
769 Seizure & Headache Age 0-17 w/o CC Medical
770 Resp Infect & Inflam Age 0-17 w CC Medical
771 Resp Infect & Inflam Age 0-17 w/o CC Medical
772 Simple Pneumonia, Pleurisy Age 0-17 w CC Medical
773 Simple Pneumonia, Pleurisy Age 0-17 w/o CC Medical
774 Bronchitis & Asthma Age 0-17 w CC Medical
775 Bronchitis & Asthma Age 0-17 w/o CC Medical
776 Esphgitis, Ge, Misc Dig Dis Age 0-17 w CC Medical
777 Esphgitis, Ge, Misc Dig Dis Age 0-17 w/o CC Medical
778 Other Digestive System Dx Age 0-17 w CC Medical
779 Other Digestive System Dx Age 0-17 w/o CC Medical
780 Ac Leukemia wo Maj OR Proc Age 0-17 w CC Medical
781 Ac Leukemia wo Maj OR Proc Age 17 w CC Medical
783 Ac Leukemia wo Maj OrRProc Age >17 w/o CC Medical
784 Acq Hem Anemia,Sickle Cell Crisis Age

DRG Description DRG Type
797 Lower Extremity Revascularization w/o CC Surgical
798 Tuberculosis w/Operating Room Procedure Surgical
799 Tuberculosis Left Against Medical Advise Medical
800 Tuberculosis w/CC Medical
801 Tuberculosis w/o CC Medical
802 Pneumocyctosis Medical
803 Allogeneic Bone Marrow Transplant Surgical
804 Autologous Bone Marrow Transplant Surgical
805 Simultaneous Kidney/Pancreas Transplant Surgical
806 Combined Ant/Posterior Spinal Fus w/CC Surgical
807 Combined Ant/Posterior Spinal Fus w/o CC Surgical
808 Percutaneous Cardio Proc w Ami, Hf, Or Shk Surgical
809 Other Cardiothoracic Proc w/Pdx Cong Ano Surgical
This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a
guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on
the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies
and procedures and claims editing logic. This policy does not apply to Tufts Health Plan Medicare Preferred, Uniformed Services Family Health Plan or
Private Health Care Systems (PHCS) network Members. Providers in the New Hampshire service area are subject to CIGNA HealthCare’s provider
arrangement for the purpose of CareLink SM Members.
Originated 06/2005, Revised 07/2006 23 of 23 Tufts Health Plan – DRG List