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DRG codes and how much you can claim using the NIPHS

You can claim payment for whichever is the smaller amount:

  • the cost of your healthcare in Northern Ireland
  • the cost of the same healthcare in the public system in the Republic of Ireland

For example, if your healthcare in Northern Ireland costs €2,000 and in the Republic of Ireland it costs €1,500, you will receive €1,500.

Calculating the cost in the public health system in the Republic of Ireland

We use diagnostic-related group (DRG) codes to calculate repayments for treatment under the Northern Ireland Planned Healthcare Scheme (NIPHS).

DRG codes apply to repayments for inpatient and day case care patients.

  • inpatient care is when you stay overnight in a hospital
  • day case care is when you are admitted to hospital but do not stay overnight

Outpatient care is planned healthcare that does not involve an admission or overnight hospital stay.

Outpatient healthcare claims

Inpatient and day case patients can use DRG codes to check how much a treatment might cost in the Republic of Ireland’s public health system.

DRG codes and prices

When you are an inpatient or day case patient in a public hospital in the Republic of Ireland, the HSE assigns a DRG code to your case. We do this when you are discharged.

We select one DRG code that covers your case.

This includes:

  • your diagnosis
  • your full medical information
  • the procedures you had - this can be one or more procedures
  • all the health care services you received during your admission

Each DRG code has a price for either inpatient or day case care. We calculate your repayment based on the setting (inpatient or day case care) where you would have had the procedure in the Republic of Ireland.

We review and update these prices every year. Prices can go up or down based on changes in clinical practice.

Check the most common DRG codes and prices

We have published a guide to the most common procedures patients have using the NIPHS scheme.

The guide includes the:

  • most common procedures patients get
  • most likely DRG code for the procedure
  • prices for inpatient or day case care, whichever is standard in the Republic of Ireland

Use this guide to estimate how much you might be repaid.

Guide to common DRG codes and prices (PDF, KB, pages)

Full DRG price lists

If you can’t find a procedure in the guide you can check the full price lists.

For older claims check past price lists.

Choosing a different DRG code

Sometimes a consultant might select a different DRG code to the one in the guide. They can only do this after they have completed your treatment and have all the medical information.

The medical notes from your episode of care must support this choice.

Review of DRG codes

We sometimes ask our Healthcare Pricing Office (HPO) to check the selected DRG code. For example, if the DRG code is not usually used in the Republic of Ireland for the treatment you received.

The HPO will review the medical information you provide. They will confirm the correct DRG code for the healthcare you received. The DRG code confirmed by the HPO decides the repayment you can get.

Outpatient healthcare claims

Outpatient care is usually when you have a hospital appointment for a consultation. Sometimes you may have a diagnostic test, minor procedure or treatment. You are not admitted to hospital and you do not stay overnight.

These are the maximum claims for one or more outpatient appointments, including treatment, on the same day in a hospital in Northern Ireland.

The maximum claim for appointments from 1 May 2023 is €194.

The maximum claim for appointments between 1 March 2021 to 30 April 2023 is €178.

There are different types of outpatient appointments such as x-rays, CT scans, biopsy or MRI scans. If you have more than 1 outpatient appointment on the same day, you can only claim the maximum payment.

DRG code changes for clinicians

Cataract surgery

The code we expect for most cataract treatments is:

  • DRG C16Z LENS INTERVENTIONS

The codes for the most complex cataract treatments are:

  • DRG C15A GLAUCOMA/CMPLX CATARACT INTERV, MAJC
  • DRG C15B GLAUCOMA/CMPLX CATARACT INTERV, MINC

Injections to joints

The code DRG 140Z INFUSION FOR MUSCLSKLT DIS, SD is no longer in use. This was used to cover all injections and infusions for musculoskeletal disorders until 2024.

There are now 5 DRG codes for injections to joints. They are ‌based on the reason for the injection. View the codes and their criteria in the guide to common DRG codes and costs (PDF, 595 KB, 11 pages).

Hip replacement

The code we expect for unilateral hip replacement is:

  • DRG I33B HIP REPLACE, NON-TRAUMA, MINC

The code to use for trauma cases is:

  • DRG I03B HIP REPLACEMENT, TRAUMA, MINC

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