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    v1.0.28
    OpenPayerBilling CodesDiseases and Disorders of the Ear, Nose, Mouth and ThroatDRG 159-dental-and-oral-diseases-without-cc-mcc
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    Dental and Oral Diseases without CC/MCC: Inpatient Reimbursement Overview

    DRG 159 covers inpatient stays for dental and oral diseases without Complication or Comorbidity or Major Complication or Comorbidity, focusing on straightforward procedures and infections limited to the oral cavity. Classification in this Diagnosis-Related Group matters because it determines the Medicare prospective payment level and reflects lower expected resource use compared with more complex oral and maxillofacial cases.

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    DRG 159 Overview

    DRG 159 covers hospital admissions for dental and oral diseases without a Complication or Comorbidity or Major Complication or Comorbidity, typically including tooth extractions, abscess drainage, and treatment of non-complex oral infections when no significant systemic complications are present. This Diagnosis-Related Group groups cases with relatively low resource use compared with more complex oral and maxillofacial conditions. For Medicare payment, classification in DRG 159 influences the base prospective payment and affects hospital revenue and resource allocation for routine dental and oral inpatient care. Accurate coding of diagnosis and comorbid conditions determines whether a case remains in DRG 159 or is assigned to a higher-paying Diagnosis-Related Group.

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    National Payment Rates

    Across commercial payers the reported rate range spans from $370 (BCBS min) up to $24K (Anthem max), with payer means clustering between $6.6K and $12K; the widest observed spread is between BCBS (min $370) and Anthem (max $24K). See the table and chart below for payer-specific distributions and percentile details. Commercial benchmarks show notable variability by payer and percentile.

    CMS 2023 national data represent Medicare fee-for-service inpatient payments reported 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 159. These figures reflect national Medicare payment experience and discharge volume for the DRG in 2023.

    Average Total PaymentAverage Submitted ChargesAverage Medicare PaymentTotal Discharges
    $7.7K$34K$5.3K580

    Patient Population

    The DRG’s patient population skews toward a mixed-age cohort but with substantial representation among Medicare-age beneficiaries given the inclusion in CMS inpatient data; many cases fall within the working-age commercial market as reflected by the commercial payer benchmarks. Overall, the payer mix is mixed between Medicare and private/commercial payers rather than being exclusively Medicare-age or exclusively working-age. Payer distributions in the benchmarks suggest meaningful volume from both Medicare and commercial sources.

    State Payment Rates

    State: Alaska1 / 49

    Alaska Benchmarks

    Alaska’s DRG 159 rates span from roughly 11K to 29K across payers, with a cluster at 11K and a notable high outlier at 29K. The most notable deviation from national averages is the elevated Cigna mean (~17K) and its 29K max, which push the state mean above several national payer means. Reference the table and chart below for payer-level distributions and percentile details.

    Key Insights for Alaska

    • Cigna is the highest-paying payer in Alaska with a mean of 17K, while Blue Cross Blue Shield and Anthem are the lowest, both at a mean of 11K.
    • Alaska’s payer range (min ~11K to max ~29K) shows a wider top-end than national medians, with Cigna’s mean (~17K) sitting above several national payer means, indicating meaningful upward deviation at the high end.

    Clinical Trials

    • Studies evaluating novel acute management and surgical techniques for severe odontogenic infections and maxillofacial abscesses that require inpatient care. These trials often enroll adults and pediatric patients admitted for airway-compromising infections or deep space head and neck abscesses, comparing approaches such as timing of incision and drainage, adjunctive local care, or perioperative airway management strategies. Results inform protocol development for inpatient teams and influence resource use, length of stay, and complication rates important to hospital reimbursement and DRG assignment.
    • Comparative effectiveness research comparing different restorative and extraction strategies for patients hospitalized with advanced dental caries, pulpitis, or failed dental work leading to systemic symptoms. These studies enroll medically complex patients (for example, those with diabetes, anticoagulation, or immunosuppression) to compare outcomes of conservative endodontic-based care versus extraction and prosthetic planning, measuring short-term morbidity, need for readmission, and downstream dental service utilization. Findings guide clinicians and payers on which inpatient care pathways reduce complications and subsequent costs, affecting care coordination and post-discharge reimbursement planning.
    • Post-discharge outcomes and care-transition studies focusing on access to outpatient dental follow-up, oral rehabilitation, and prevention among patients discharged after inpatient dental procedures or infection management. These prospective cohort or health-services trials follow patients for readmissions, ongoing infection, oral function, pain control, and enrollment in dental care programs, often targeting underserved populations with limited dental access. Understanding these outcomes helps hospitals and payers design discharge planning, community partnerships, and value-based programs to reduce readmissions and improve long-term oral health outcomes tied to DRG performance.

    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

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    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.
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    Mean Rates by Payer — National — DRG 159
    Mean Rates by Payer — Alaska — DRG 159