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 CodesDiseases and Disorders of the Ear, Nose, Mouth and ThroatDRG 158-dental-and-oral-diseases-with-cc
    Ask Trek AI about this page

    Dental and Oral Diseases with CC: Inpatient Reimbursement Overview

    DRG 158 encompasses dental and oral disease hospitalizations accompanied by a Complication or Comorbidity, such as severe infection or complex surgical intervention. It matters for inpatient reimbursement because the Complication or Comorbidity classification raises expected resource use and affects Medicare payment grouping.

    Customize your policy alerts

    Sign up for drg 158 policy alerts

    Get alerted when payer policies referencing 158 are released or updated.

    Monitor payer policy activity

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

    DRG 158 Overview

    DRG 158 covers hospitalizations for dental and oral diseases with Complication or Comorbidity that require inpatient care, including significant infections, extensive oral surgery, or complex dental procedures in medically complex patients. This Diagnosis-Related Group groups cases where an additional Complication or Comorbidity increases resource use and length of stay compared with non-complicated dental admissions. For Medicare payment, the presence of a Complication or Comorbidity in DRG 158 affects relative reimbursement by reflecting higher expected costs and resource intensity. Accurate clinical coding and documentation determine grouping into this Diagnosis-Related Group and therefore influence Medicare inpatient reimbursement.

    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

    Payer rates for DRG 158 range from a low around $370 to a high of $32K across the payers shown, with the widest spread observed between Anthem ($390–$32K) and BCBS ($370–$24K) in the provided table and chart. The payer table and accompanying chart below illustrate median and quartile values for major national payers including Blue Cross Blue Shield, Anthem, Cigna, and Aetna. Note that mean and median values vary substantially by payer, indicating variation in negotiated commercial rates versus benchmarks.

    The CMS 2023 data represent national Medicare fee-for-service inpatient payments published under the CMS Provider Utilization and Payment Data program. The table below shows average total payment, average submitted covered charges, average Medicare payment amount, and total discharges for DRG 158. Values reflect national aggregates for Medicare beneficiaries in 2023.

    Average Total PaymentAverage Submitted ChargesAverage Medicare PaymentTotal Discharges
    $9.6K$45K$7.2K2.9K

    Patient Population

    The DRG 158 population skews toward a mixed-age group but with substantial Medicare representation, reflecting many discharges among Medicare-age beneficiaries alongside working-age commercially insured patients. Overall, the case mix includes both Medicare and private/commercial payers rather than being exclusively Medicare-age or exclusively working-age. This implies a blended payer mix for utilization and payment analyses.

    State Payment Rates

    State: Alaska1 / 49

    Alaska Benchmarks

    Alaska shows a payer mean range from 14K to 22K across payers, with Cigna at the high end and Blue Cross Blue Shield and Anthem at the low end. Cigna’s mean of 22K stands out as the most notable deviation above the national context, while BCBS and Anthem sit at a consistent 14K. See the table and chart below for payer-level detail.

    Key Insights for Alaska

    • Highest payer: Cigna with a mean of 22K; Lowest payers: Blue Cross Blue Shield and Anthem, each with a mean of 14K.
    • Alaska’s payer means range from 14K to 22K, a narrower and generally higher distribution than some national means; Cigna’s mean at 22K meaningfully exceeds the national Anthem/Cigna/Aetna averages shown in the national benchmarks.

    Clinical Trials

    • Acute surgical and perioperative intervention studies: randomized or prospective cohort studies evaluating different operative techniques, anesthesia approaches, or perioperative infection control protocols for patients undergoing inpatient management of severe dental and oral infections, complex extractions, or maxillofacial procedures with complications (the CC in this DRG often denotes comorbid conditions such as diabetes or immunosuppression). These trials enroll hospitalized adults who require urgent operative care to compare outcomes like complication rates, length of stay, and need for reoperation. Results inform surgeons, hospitalists, and payers about which acute care strategies reduce resource use and readmissions while improving short-term clinical outcomes.
    • Comparative effectiveness research on inpatient medical management and comorbidity optimization: studies comparing antibiotic regimens, glycemic control strategies, or protocols for managing anticoagulation and other comorbid conditions in patients admitted with dental and oral disease complicated by systemic illness. These investigations typically target medically complex inpatients (older adults, patients with diabetes, cardiovascular disease, or chronic kidney disease) to determine which non-surgical or adjunctive treatments reduce progression of infection, ICU transfers, and overall costs. Findings are relevant to clinicians and payers because optimized medical management can lower complication-driven resource utilization and influence bundle payment performance.
    • Post-discharge outcomes and care-coordination trials: prospective studies of discharge planning, dental rehabilitation pathways, or outpatient follow-up models (including tele-dentistry and community dental partnerships) for patients discharged after inpatient treatment for dental/oral disease with complications. These trials follow patients at risk for recurrence, delayed healing, or functional impairment—often those with social determinants impacting oral health access—to assess rates of readmission, emergency visits, prosthetic/rehabilitation needs, and patient-reported outcomes. Results guide hospitals and payers on investments in transitional care programs that reduce readmissions and improve long-term function and cost-effectiveness.

    Related Codes

    135-SINUS-AND-MASTOID-PROCEDURES-WITH-CC-MCC

    Sinus and Mastoid Procedures with CC/MCC: Inpatient Reimbursement Overview

    136-SINUS-AND-MASTOID-PROCEDURES-WITHOUT-CC-MCC

    Sinus and Mastoid Procedures without CC/MCC: Inpatient Reimbursement Overview

    137-MOUTH-PROCEDURES-WITH-CC-MCC

    Mouth Procedures with CC/MCC: Inpatient Reimbursement Overview

    138-MOUTH-PROCEDURES-WITHOUT-CC-MCC

    Mouth Procedures without CC/MCC: Inpatient Reimbursement Overview

    139-SALIVARY-GLAND-PROCEDURES

    Salivary Gland Procedures: Inpatient Reimbursement Overview

    140-MAJOR-HEAD-AND-NECK-PROCEDURES-WITH-MCC

    Major Head and Neck Procedures with MCC: Inpatient Reimbursement Overview

    141-MAJOR-HEAD-AND-NECK-PROCEDURES-WITH-CC

    Major Head and Neck Procedures with CC: Inpatient Reimbursement Overview

    142-MAJOR-HEAD-AND-NECK-PROCEDURES-WITHOUT-CC-MCC

    Major Head and Neck Procedures without CC/MCC: Inpatient Reimbursement Overview

    143-OTHER-EAR-NOSE-MOUTH-AND-THROAT-O-R-PROCEDURES-WITH-MCC

    Other Ear, Nose, Mouth and Throat O.R. Procedures with MCC: Inpatient Reimbursement Overview

    144-OTHER-EAR-NOSE-MOUTH-AND-THROAT-O-R-PROCEDURES-WITH-CC

    Other Ear, Nose, Mouth and Throat O.R. Procedures with CC: Inpatient Reimbursement Overview

    Showing 1–10 of 24

    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 158
    Mean Rates by Payer — Alaska — DRG 158