This article covers Idaho’s workers' compensation payment calculation resources and acceptable charges rules for hospital services and Ambulatory Surgical Centers (ASCs).

2026 Payment Calculation Resources

Hospital Inpatient: MS-DRG

• Table 5: List of FY26 MS-DRGs. Relative Weights  (Effective October 1, 2025)

Hospital Outpatient & Ambulatory Surgery Centers (ASC)

• 2026 Addendum B - Weights by CPT code (Effective January 1, 2026)
• 2026 Addendum D1 - Status Indicators (Effective January 1, 2026)

Hospitals & Ambulatory Surgery Centers (ASCs) Charges

IDAPA 17.01.01.803.03 - Acceptable Charges For Medical Services Provided By Hospitals And Ambulatory Surgery Centers Under The Idaho Worker's Compensation Law.

The following standards shall be used to determine the acceptable charge for Hospitals and ASCs.

a. Critical Access Hospitals.

The standard for determining the acceptable charge for inpatient and outpatient services provided by a Critical Access Hospital is ninety percent (90%) of the reasonable charge.

Implantable hardware charges shall be reimbursed at the rate of the actual cost plus fifty percent (50%).

b. Hospital Inpatient Services.

The standard for determining the acceptable charge for inpatient services provided by Hospitals, other than Critical Access Hospitals, is calculated by multiplying the base rate by the current MS-DRG weight for that service. The base rate for inpatient services is ten thousand two hundred dollars ($10,200). Inpatient services that do not have a relative weight shall be paid at eighty-five percent (85%) of the reasonable charge; however, Implantable Hardware charges billed for services without an MS-DRG weight shall be reimbursed at the rate of actual cost plus fifty percent (50%).

c. Hospital Outpatient and ASC Services. The standard for determining the acceptable charge for outpatient services provided by Hospitals (other than Critical Access Hospitals) and for services provided by ASCs is calculated by multiplying the base rate by the Medicare Hospital Outpatient Prospective Payment System APC weight in effect on the first day of January of the current calendar year.

The base rate for Hospital outpatient services is one hundred forty dollars and seventy-five cents ($140.75).

The base rate for ASC services is ninety-one dollars fifty cents ($91.50).

i. Medical services for which there is no APC weight listed shall be reimbursed at seventy-five percent (75%) of the reasonable charge, except when bundled with another service appearing on the same bill or is a service defined in 803.03.c.ii. - iv. of this rule.

ii. Status indicator N codes or items with no CPT or HCPCS code shall receive no payment except as provided in Subparagraph 803.03.c.ii.(1) or 803.03.c.ii.(2) of this rule.

iii. Outpatient physical, occupational, and speech therapy services will be reimbursed according to the allowable professional charge under Subsection 803.02 of this rule.

iv. Status indicator Q codes are not subject to composite APC packaging standards.

(1) Implantable Hardware may be eligible for separate payment under Subparagraph 03.d.iii. of this rule.

d. Additional Hospital Payments. When the charge for a medical service provided by a Hospital (other than a Critical Access Hospital) meets the following standards, additional payment shall be made for that service, as indicated.

i. Inpatient Threshold Exceeded. When the charge for a Hospital inpatient MS-DRG coded service exceeds the sum of thirty thousand dollars ($30,000) plus the payment calculated under the provisions of Paragraph 03.b. of this rule, then the total payment for that service shall be the sum of the MS-DRG payment and the amount charged above that threshold multiplied by seventy-five percent (75%). Implantable charges shall be excluded from the calculation for an additional inpatient payment under this Subparagraph.

ii. Inpatient Implantable Hardware. Hospitals may seek additional reimbursement beyond the MSDRG payment for invoiced Implantable Hardware where the aggregate invoice cost is greater than ten thousand dollars ($10,000). Additional reimbursement shall be the invoice cost plus an amount which is equal to ten percent (10%) of the invoice cost, but which does not exceed three thousand dollars ($3,000). Handling and freight charges shall be included in invoice cost.

iii. Outpatient Implantable Hardware. Hospitals and ASCs may seek additional reimbursement beyond the APC payment for invoiced Implantable Hardware where the aggregate invoice cost is greater than five hundred dollars ($500). Additional reimbursement shall be the invoice cost plus an amount which is equal to ten percent (10%) of the invoice cost, but which does not exceed one thousand dollars ($1,000). Handling and freight charges shall be included in invoice cost.

e. Adjustment of Hospital and ASC Base Rates. The Commission may periodically adjust the base rates set out in Paragraphs 803.03.b. and 803.03.c. of this rule to reflect changes in inflation or market conditions.

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