Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerBilling CodesPre-MDCDRG 001-heart-transplant-or-implant-of-heart-assist-system-with-mcc
    Ask Trek AI about this page

    Heart Transplant or Implant of Heart Assist System with MCC: Inpatient Reimbursement Overview

    DRG 001 addresses heart transplant or implantation of a heart assist system with Major Complication or Comorbidity, encompassing the most complex cardiac surgical admissions. This Diagnosis-Related Group is critical for inpatient reimbursement because it represents high resource utilization and significantly impacts Medicare payment determinations.

    Customize your policy alerts

    Sign up for drg 001 policy alerts

    Get alerted when payer policies referencing 001 are released or updated.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    DRG 001 Overview

    DRG 001 covers inpatient admissions for heart transplant or implantation of a heart assist system with Major Complication or Comorbidity. This Diagnosis-Related Group captures the highest complexity cardiac surgical cases that drive substantial resource use, including postoperative intensive care and prolonged hospitalization. It matters for Medicare payment because it represents one of the most resource-intensive Diagnosis-Related Groups, influencing base payment, outlier considerations, and hospital financial planning. Precise coding of diagnoses and procedures determines assignment to this Diagnosis-Related Group and consequent reimbursement tiers.

    Table of contents

    Progress1 / 5

    Explore openpayer tools

    • Billing CodesCPT, HCPCS, DRG & more
    • Reimbursement RatesCommercial vs. Medicare rate reports
    • ProvidersHospitals & facilities
    • PayersPlans & market footprint
    • Taxonomy CodesNUCC specialty codes
    • ModifiersCPT modifiers & usage
    • Prior AuthorizationPA policies by payer & drug
    • Timely FilingFiling deadlines by payer
    • Coverage CriteriaMedical necessity by payer
    • Payer ContactsClaims, PA & appeals contacts
    View all tools

    National Payment Rates

    Across national payers the observed rate range spans roughly $170K to $990K, with Anthem and Blue Cross Blue Shield showing the highest maximums. The widest spread between a payer’s minimum and maximum is seen with Anthem (up to $990K). See the table and chart below for payer-specific quartiles and medians for Anthem, Aetna, Cigna, and BCBS.

    The CMS 2023 dataset reflects national Medicare fee-for-service inpatient payments reported under the CMS Provider Utilization and Payment Data program. The table below shows average total payment ($332.9k), average submitted covered charges ($1.5m), average Medicare payment ($281.5k), and total discharges (2.0k).

    Average Total PaymentAverage Submitted ChargesAverage Medicare PaymentTotal Discharges
    $330K$1.5M$280K2K

    Patient Population

    This DRG’s population includes both Medicare-age beneficiaries and non-Medicare commercial enrollees, producing a mixed-age payer mix skewed toward older adults. Many admissions are covered by Medicare fee-for-service, but a substantial share comes from private/commercial payers such as Aetna, Anthem, Cigna and BCBS. The overall payer mix therefore reflects a combination of Medicare-age and working-age patients rather than exclusively one group.

    State Payment Rates

    State: Alaska1 / 49

    Alaska Benchmarks

    In Alaska for DRG 001, mean rates across payers range from $440K to $490K, with Cigna at the top end and Anthem and Blue Cross Blue Shield at the low end. This represents a narrow state-level spread and a modest elevation above some national averages at the top payer. See the table and chart below for payer-specific distribution and percentile detail.

    Key Insights for Alaska

    • Cigna is the highest-paying payer in Alaska at a mean of $490K, while Anthem and Blue Cross Blue Shield are tied as the lowest payers at a mean of $440K.
    • The statewide mean range spans from $440K to $490K, a relatively tight band compared with national variability; Alaska’s highest mean ($490K) modestly exceeds the national mean benchmarks shown but the lowest means ($440K) align with national medians, indicating limited upside in the market.

    Clinical Trials

    • Perioperative management and device optimization trials: These studies focus on immediate intraoperative and early postoperative strategies for heart transplant recipients and patients receiving durable or temporary mechanical circulatory support devices, investigating protocols for anticoagulation timing, hemodynamic support algorithms, infection prophylaxis, and strategies to minimize right ventricular failure after device implantation. The patient population includes adults undergoing orthotopic heart transplantation or implantation of left ventricular assist devices (LVADs) or temporary extracorporeal support, often with multiple organ dysfunction or high surgical risk. Results are relevant to providers for improving survival and complication rates in the index hospitalization and to payers because optimized perioperative protocols can reduce intensive care length of stay, device-related complications, and readmissions that drive high costs under this DRG.
    • Comparative effectiveness studies of long-term support versus transplantation candidacy: These trials compare outcomes between patients who proceed to durable mechanical circulatory support as destination therapy or bridge-to-transplant versus those listed for transplantation, assessing survival, quality of life, functional status, and resource utilization over months to years. The studies enroll advanced heart failure patients who meet criteria for transplantation or durable assist devices, including those with comorbidities that influence candidacy decisions. Findings inform clinicians and transplant programs about patient selection and timing decisions, and inform payers and hospitals about downstream costs and expected trajectories linked to an index hospitalization coded under this DRG.
    • Post-discharge outcomes and readmission reduction trials: These pragmatic trials evaluate care-transition interventions such as structured discharge planning, remote hemodynamic monitoring, telehealth follow-up, and outpatient anticoagulation or infection surveillance programs aimed at reducing 30- and 90-day readmissions, device-related complications, and graft rejection episodes. The participant pool consists of recent heart transplant recipients and patients discharged with an implanted assist device, including those with varying social support and frailty levels that impact post-acute care needs. This research is critical for providers to identify effective outpatient management pathways that improve long-term outcomes and for payers to understand interventions that can lower costly readmissions and post-acute care expenditures associated with this DRG.

    Related Codes

    002-HEART-TRANSPLANT-OR-IMPLANT-OF-HEART-ASSIST-SYSTEM-WITHOUT-MCC

    Heart Transplant or Implant of Heart Assist System without MCC: Inpatient Reimbursement Overview

    003-ECMO-OR-TRACHEOSTOMY-WITH-MV-96-HOURS-OR-PRINCIPAL-DIAGNOSIS-EXCEPT-FACE-MOUTH-AND-NECK-WITH-MAJOR-O-R-PROCEDURES

    ECMO or Tracheostomy with MV >96 Hours: Inpatient Reimbursement Overview

    004-TRACHEOSTOMY-WITH-MV-96-HOURS-OR-PRINCIPAL-DIAGNOSIS-EXCEPT-FACE-MOUTH-AND-NECK-WITHOUT-MAJOR-O-R-PROCEDURES

    Tracheostomy with Mechanical Ventilation >96 Hours: Inpatient Reimbursement Overview

    005-LIVER-TRANSPLANT-WITH-MCC-OR-INTESTINAL-TRANSPLANT

    Liver Transplant with MCC or Intestinal Transplant: Inpatient Reimbursement Overview

    006-LIVER-TRANSPLANT-WITHOUT-MCC

    Liver Transplant without Major Complication or Comorbidity: Inpatient Reimbursement Overview

    007-LUNG-TRANSPLANT

    Lung Transplant: Inpatient Reimbursement Overview

    008-SIMULTANEOUS-PANCREAS-AND-KIDNEY-TRANSPLANT

    Simultaneous Pancreas and Kidney Transplant: Inpatient Reimbursement Overview

    010-PANCREAS-TRANSPLANT

    Pancreas Transplant: Inpatient Reimbursement Overview

    011-TRACHEOSTOMY-FOR-FACE-MOUTH-AND-NECK-DIAGNOSES-OR-LARYNGECTOMY-WITH-MCC

    Tracheostomy/Laryngectomy with MCC: Inpatient Reimbursement Overview

    012-TRACHEOSTOMY-FOR-FACE-MOUTH-AND-NECK-DIAGNOSES-OR-LARYNGECTOMY-WITH-CC

    Tracheostomy and Laryngectomy with CC: Inpatient Reimbursement Overview

    Showing 1–10 of 16

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
    Published by

    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

    Mean Rates by Payer — National — DRG 001
    Mean Rates by Payer — Alaska — DRG 001