Intraocular Procedures without CC/MCC DRG - Reimbursement

Summary & Overview

Intraocular Procedures without CC/MCC: Inpatient Reimbursement Overview

DRG 117 encompasses inpatient intraocular procedures performed without a Complication or Comorbidity or Major Complication or Comorbidity, representing lower-complexity eye operations relevant to hospital reimbursement. This classification matters because it determines the Medicare payment tier for these procedures and influences hospital coding, billing, and resource allocation.

Intraocular Procedures without CC/MCCDRG Intraocular Procedures without CC/MCCDRG 117Diagnosis-Related GroupInpatient ReimbursementMedicareOphthalmologyCataract SurgeryEye Surgery

DRG 117 Overview

DRG 117 covers inpatient admissions for intraocular surgical procedures without a Complication or Comorbidity or Major Complication or Comorbidity. It typically includes straightforward cataract and other intraocular operations where complexity is low and no significant coexisting conditions are reported. This Diagnosis-Related Group matters for Medicare payment because it categorizes lower-resource ocular procedures into a payment tier that affects hospital reimbursement and resource planning. Understanding the clinical scope helps hospitals align coding and billing with expected payment levels.

National Payment Rates

Across commercial payers the observed rate range spans roughly from $370 up to $37K, with Anthem showing the highest maximum and BCBS the lowest minimum in the table below. The widest spread between payer minimums and maximums is therefore about $37K. See the payer table and accompanying chart below for the full distribution by payer and quartiles.

Mean Rates by Payer — National — DRG 117

The CMS 2023 data represent national Medicare fee-for-service inpatient payments reported under the CMS Provider Utilization and Payment Data program. The table below shows average total payment ($12.3k), average submitted covered charges ($62.2k), average Medicare payment amount ($9.4k), and total discharges (113).

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

In AK the DRG 117 mean payment range spans from $17K (Anthem and Blue Cross Blue Shield) up to $26K (Cigna), a relatively narrow state spread. Cigna stands out as the primary high outlier versus the other AK payers. This distribution deviates from national patterns where median values sit closer together; see the table and chart below for details.

Key Insights for Alaska

Highest payer: Cigna (mean $26K) — notably higher than other state payers in AK.
Lowest payers: Anthem and Blue Cross Blue Shield (mean $17K) — both at the bottom of the state range.
State mean spread ($17K–$26K) shows Cigna outlier above national median ranges, while Anthem/BCBS sit below typical national medians.

Clinical Trials

Acute perioperative intervention trials: studies assessing intraoperative techniques, anesthetic approaches, or immediate perioperative adjuncts (for example, different methods of controlling intraocular inflammation, incision closure techniques, or intraoperative antibiotic delivery) in adults undergoing intraocular procedures without major complications. These trials enroll patients at the time of surgery to evaluate short-term safety, procedural success, and reductions in early complications such as endophthalmitis, anterior chamber inflammation, or hemorrhage. Results are directly relevant to providers and payers by identifying practices that reduce length of stay, readmissions, and short-term resource utilization in this DRG cohort.
Comparative effectiveness studies of procedural approaches and devices: randomized or pragmatic trials comparing alternative intraocular procedure techniques or commonly used surgical devices (for example, different lens implantation strategies, minimally invasive instrumentation, or adjunctive viscoelastics) in patients undergoing elective intraocular surgery without complicating comorbidities. These studies focus on functional outcomes (visual acuity, refractive accuracy), complication rates, and need for additional procedures over weeks to months, addressing which standard approaches deliver the best value. Payers and hospital systems use this evidence to guide formularies, device purchasing, and bundled payment models by favoring approaches that improve outcomes while controlling costs for this DRG group.
Post-discharge outcomes and quality-of-life studies: observational cohorts or registry-based research tracking recovery trajectories, patient-reported outcomes, and late complications (such as posterior capsule opacification or secondary interventions) after uncomplicated intraocular procedures. These studies typically follow patients from discharge through months or years to capture downstream utilization (clinic visits, laser capsulotomy, secondary surgeries) and patient satisfaction, helping quantify long-term costs and benefits. Insights inform discharge planning, follow-up scheduling, and risk stratification policies used by clinicians and payers to optimize care pathways and reimbursement strategies for patients coded to this DRG.

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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.

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$12K	$62K	$9.4K	110