Dental and Oral Diseases with CC DRG Reimbursement Guide

Summary & Overview

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.

Dental and Oral DiseasesDRG Dental and Oral Diseases with CCDRG 158Diagnosis-Related GroupInpatient ReimbursementMedicareOral SurgeryDental InfectionHospital MedicineSurgical Dentistry

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.

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.

Mean Rates by Payer — National — DRG 158

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

152-OTITIS-MEDIA-AND-URI-WITH-MCC

Otitis Media and URI with MCC: Inpatient Reimbursement Overview

153-OTITIS-MEDIA-AND-URI-WITHOUT-MCC

Otitis Media and URI without MCC: Inpatient Reimbursement Overview

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

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

157-DENTAL-AND-ORAL-DISEASES-WITH-MCC

Dental and Oral Diseases with MCC: Inpatient Reimbursement Overview

145-OTHER-EAR-NOSE-MOUTH-AND-THROAT-O-R-PROCEDURES-WITHOUT-CC-MCC

Other Ear, Nose, Mouth and Throat O.R. Procedures without CC/MCC: Inpatient Reimbursement Overview

150-EPISTAXIS-WITH-MCC

Epistaxis with Major Complication or Comorbidity: Inpatient Reimbursement Overview

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

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

137-MOUTH-PROCEDURES-WITH-CC-MCC

Mouth Procedures with CC/MCC: Inpatient Reimbursement Overview

146-EAR-NOSE-MOUTH-AND-THROAT-MALIGNANCY-WITH-MCC

Ear, Nose, Mouth and Throat Malignancy with MCC: Inpatient Reimbursement Overview

139-SALIVARY-GLAND-PROCEDURES

Salivary Gland Procedures: Inpatient Reimbursement Overview

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Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$9.6K	$45K	$7.2K	2.9K

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Mean Rates by Payer — Alaska — DRG 158

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.