Major Chest Procedures with CC: Inpatient Reimbursement Overview

DRG 164 encompasses major chest surgical procedures performed on inpatient beneficiaries when a Complication or Comorbidity is present; these are higher-acuity thoracic operations with increased resource needs. Correct classification matters for inpatient reimbursement because the Complication or Comorbidity status increases the assigned Medicare Severity Diagnosis-Related Group and thereby influences Centers for Medicare & Medicaid Services payment.

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DRG 164 Overview

DRG 164 covers major thoracic surgical procedures on the chest with an accompanying Complication or Comorbidity, including extensive resections, complex thoracotomies, and procedures on the mediastinum or pleura. These cases typically involve significant intraoperative resources and postoperative management that increase hospital resource use. For Medicare inpatient payment, the presence of a Complication or Comorbidity elevates the classification and affects the payment relative to cases without such comorbid conditions. Accurate documentation and coding of operative procedures and concurrent conditions determine appropriate Medicare Severity Diagnosis-Related Group assignment and reimbursement.

National Payment Rates

Across payers the observed rate range spans from about $1.1K (BCBS 25th percentile) up to $95K (Anthem max), with mean payments varying widely by payer. Anthem and Aetna show higher median and upper-tail values while BCBS and Cigna report lower medians, producing the widest spread between the highest max (Anthem $95K) and lower-mid payer medians. See the table and chart below for payer-specific percentiles and distribution details.

The CMS 2023 data reflect national Medicare fee-for-service inpatient payments reported under the CMS Provider Utilization and Payment Data program. The table below shows average total payment ($24.6k), average submitted covered charges ($122.5k), average Medicare payment ($19.8k), and total discharges (15.1k).

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$25K	$120K	$20K	15K

Patient Population

This DRG generally involves a mixed-age population but skews toward Medicare-age beneficiaries given the high share of inpatient Medicare discharges in national datasets. Commercial/private payers cover a proportion of working-age patients, producing a mixed payer mix. The overall population therefore reflects both Medicare-age predominance and a notable working-age component covered by commercial plans.

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

For DRG 164, mean rates in Alaska range from $39K (Anthem and Blue Cross Blue Shield) up to $61K (Cigna), a substantial spread across payers. The most notable deviation from national averages is Cigna’s higher mean of $61K compared with typical national means, while Anthem/Blue Cross Blue Shield sit well below national medians. See the table and chart below for payer-specific detail.

Key Insights for Alaska

Anthem is the lowest-paying payer at $39K while Cigna is the highest-paying payer at $61K, representing the largest within-state spread.
Alaska’s Cigna mean of $61K sits meaningfully above national means for major payers, while Anthem/BCBS at $39K are notably below national medians, indicating a bimodal distribution versus national averages.

Clinical Trials

Trials of perioperative ventilatory strategies and respiratory support protocols: randomized or pragmatic studies that compare different intraoperative and immediate postoperative ventilator settings, use of lung-protective ventilation, or timing and criteria for invasive versus noninvasive respiratory support in adults undergoing major thoracic surgery with complications (eg, patients with preexisting COPD, pneumonia, or acute respiratory failure). These studies focus on the acute intra- and early post-op care period to reduce pulmonary complications, duration of mechanical ventilation, and ICU stays, and are relevant because ventilator management directly affects morbidity, LOS, and resource use for DRG 164 patients. Payers and providers use this evidence to optimize protocols that can lower complication-driven costs and readmission risk.
Comparative effectiveness trials of surgical approaches and perioperative bundles for complex chest procedures: prospective cohort studies or randomized trials comparing open thoracotomy versus minimally invasive techniques (eg, VATS/robotic) combined with standardized enhanced recovery pathways in patients requiring major chest operations complicated by comorbidities (eg, cardiac disease, obesity, or infection). These trials evaluate outcomes such as complication rates, transfusion needs, length of stay, and functional recovery in a higher-risk, CC-bearing population, informing which approach yields better clinical and economic outcomes for the inpatient episode. Results are important to clinicians choosing operative strategy and to payers assessing value-based reimbursement for high-cost procedures grouped under this DRG.
Post-discharge outcomes and readmission prevention studies targeting high-risk survivors of major chest procedures: observational cohorts or interventional trials testing post-acute care interventions (eg, structured transitional care, home-based respiratory therapy, or remote monitoring) in patients discharged after complicated thoracic surgery with comorbid conditions. These studies address 30- and 90-day readmissions, late pulmonary or infectious complications, functional status, and costs of post-acute care among DRG 164 patients, providing evidence on which discharge planning and follow-up models most reduce readmissions and downstream expenditures. Such research matters to hospitals and payers aiming to improve quality metrics and control total episode spending.

Related Codes

163-MAJOR-CHEST-PROCEDURES-WITH-MCC

Major Chest Procedures with MCC: Inpatient Reimbursement Overview

165-MAJOR-CHEST-PROCEDURES-WITHOUT-CC-MCC

Major Chest Procedures without CC/MCC: Inpatient Reimbursement Overview

166-OTHER-RESPIRATORY-SYSTEM-O-R-PROCEDURES-WITH-MCC

Other Respiratory System O.R. Procedures with MCC: Inpatient Reimbursement Overview

167-OTHER-RESPIRATORY-SYSTEM-O-R-PROCEDURES-WITH-CC

Other Respiratory System O.R. Procedures with CC: Inpatient Reimbursement Overview

168-OTHER-RESPIRATORY-SYSTEM-O-R-PROCEDURES-WITHOUT-CC-MCC

Other Respiratory System O.R. Procedures without CC/MCC: Inpatient Reimbursement Overview

173-ULTRASOUND-ACCELERATED-AND-OTHER-THROMBOLYSIS-WITH-PRINCIPAL-DIAGNOSIS-PULMONARY-EMBOLISM

Ultrasound Accelerated and Other Thrombolysis with Principal Diagnosis Pulmonary Embolism: Inpatient Reimbursement Overview

175-PULMONARY-EMBOLISM-WITH-MCC-OR-ACUTE-COR-PULMONALE

Pulmonary Embolism with MCC or Acute Cor Pulmonale: Inpatient Reimbursement Overview

176-PULMONARY-EMBOLISM-WITHOUT-MCC

Pulmonary Embolism without MCC: Inpatient Reimbursement Overview

177-RESPIRATORY-INFECTIONS-AND-INFLAMMATIONS-WITH-MCC

Respiratory Infections and Inflammations with MCC: Inpatient Reimbursement Overview

178-RESPIRATORY-INFECTIONS-AND-INFLAMMATIONS-WITH-CC

Respiratory Infections and Inflammations with CC: Inpatient Reimbursement Overview

Showing 1–10 of 40

References

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.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.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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National Payment Rates

Mean Rates by Payer — National — DRG 164

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$25K	$120K	$20K	15K

Patient Population

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Mean Rates by Payer — Alaska — DRG 164

Key Insights for Alaska

Anthem is the lowest-paying payer at $39K while Cigna is the highest-paying payer at $61K, representing the largest within-state spread.
Alaska’s Cigna mean of $61K sits meaningfully above national means for major payers, while Anthem/BCBS at $39K are notably below national medians, indicating a bimodal distribution versus national averages.

Clinical Trials

Trials of perioperative ventilatory strategies and respiratory support protocols: randomized or pragmatic studies that compare different intraoperative and immediate postoperative ventilator settings, use of lung-protective ventilation, or timing and criteria for invasive versus noninvasive respiratory support in adults undergoing major thoracic surgery with complications (eg, patients with preexisting COPD, pneumonia, or acute respiratory failure). These studies focus on the acute intra- and early post-op care period to reduce pulmonary complications, duration of mechanical ventilation, and ICU stays, and are relevant because ventilator management directly affects morbidity, LOS, and resource use for DRG 164 patients. Payers and providers use this evidence to optimize protocols that can lower complication-driven costs and readmission risk.
Comparative effectiveness trials of surgical approaches and perioperative bundles for complex chest procedures: prospective cohort studies or randomized trials comparing open thoracotomy versus minimally invasive techniques (eg, VATS/robotic) combined with standardized enhanced recovery pathways in patients requiring major chest operations complicated by comorbidities (eg, cardiac disease, obesity, or infection). These trials evaluate outcomes such as complication rates, transfusion needs, length of stay, and functional recovery in a higher-risk, CC-bearing population, informing which approach yields better clinical and economic outcomes for the inpatient episode. Results are important to clinicians choosing operative strategy and to payers assessing value-based reimbursement for high-cost procedures grouped under this DRG.
Post-discharge outcomes and readmission prevention studies targeting high-risk survivors of major chest procedures: observational cohorts or interventional trials testing post-acute care interventions (eg, structured transitional care, home-based respiratory therapy, or remote monitoring) in patients discharged after complicated thoracic surgery with comorbid conditions. These studies address 30- and 90-day readmissions, late pulmonary or infectious complications, functional status, and costs of post-acute care among DRG 164 patients, providing evidence on which discharge planning and follow-up models most reduce readmissions and downstream expenditures. Such research matters to hospitals and payers aiming to improve quality metrics and control total episode spending.

Related Codes

163-MAJOR-CHEST-PROCEDURES-WITH-MCC

Major Chest Procedures with MCC: Inpatient Reimbursement Overview

165-MAJOR-CHEST-PROCEDURES-WITHOUT-CC-MCC

Major Chest Procedures without CC/MCC: Inpatient Reimbursement Overview

166-OTHER-RESPIRATORY-SYSTEM-O-R-PROCEDURES-WITH-MCC

Other Respiratory System O.R. Procedures with MCC: Inpatient Reimbursement Overview

167-OTHER-RESPIRATORY-SYSTEM-O-R-PROCEDURES-WITH-CC

Other Respiratory System O.R. Procedures with CC: Inpatient Reimbursement Overview

168-OTHER-RESPIRATORY-SYSTEM-O-R-PROCEDURES-WITHOUT-CC-MCC

Other Respiratory System O.R. Procedures without CC/MCC: Inpatient Reimbursement Overview

173-ULTRASOUND-ACCELERATED-AND-OTHER-THROMBOLYSIS-WITH-PRINCIPAL-DIAGNOSIS-PULMONARY-EMBOLISM

Ultrasound Accelerated and Other Thrombolysis with Principal Diagnosis Pulmonary Embolism: Inpatient Reimbursement Overview

175-PULMONARY-EMBOLISM-WITH-MCC-OR-ACUTE-COR-PULMONALE

Pulmonary Embolism with MCC or Acute Cor Pulmonale: Inpatient Reimbursement Overview

176-PULMONARY-EMBOLISM-WITHOUT-MCC

Pulmonary Embolism without MCC: Inpatient Reimbursement Overview

177-RESPIRATORY-INFECTIONS-AND-INFLAMMATIONS-WITH-MCC

Respiratory Infections and Inflammations with MCC: Inpatient Reimbursement Overview

178-RESPIRATORY-INFECTIONS-AND-INFLAMMATIONS-WITH-CC

Respiratory Infections and Inflammations with CC: Inpatient Reimbursement Overview

Showing 1–10 of 40

References

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.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.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.