Ariz. Admin. Code § 9-22-712.09
Current through Register Vol. 30, No. 36, September 6, 2024
| TIER | IDENTIFICATION CRITERIA | ALLOWED SPLITS |
| MATERNITY | A primary diagnosis defined as maternity 640.xx - 643.xx, 644.2x - 676.xx, v22.xx - v24.xx or v27.xx. | 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 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. | ICU |
| 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 |
Ariz. Admin. Code § R9-22-712.09