Pulmonary Embolism without MCC: Inpatient Reimbursement Overview

DRG 176 applies to inpatient stays for pulmonary embolism when no Major Complication or Comorbidity is coded, encompassing clinical evaluation and treatment specific to the embolic event. Accurate coding and documentation matter because the Diagnosis-Related Group assignment drives the Medicare bundled payment for the hospitalization and influences hospital revenue and case-mix.

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DRG 176 Overview

DRG 176 covers inpatient admissions for patients with a primary diagnosis of pulmonary embolism without a Major Complication or Comorbidity. This Diagnosis-Related Group includes the clinical management, monitoring, and treatment related to the pulmonary embolism episode of care when no higher-severity comorbid conditions are present. It matters for Medicare payment because the DRG assignment determines the bundled prospective payment for the hospitalization and affects hospital reimbursement and resource use accounting. Coding specificity for diagnoses and procedures drives proper assignment to this Diagnosis-Related Group.

National Payment Rates

Across commercial payers the observed payment range runs roughly from $5.1K (BCBS minimum) up to $33K (Anthem maximum), with mean payer values clustering near $13K. The widest spread appears with Anthem, whose max ($33K) and min ($390) produce the largest range compared with other payers. See the table and chart below for payer-level percentiles and distribution details.

The CMS 2023 dataset reflects national Medicare fee-for-service inpatient payments published under the CMS Provider Utilization and Payment Data program. The table below shows average total payment ($7.9k), average submitted covered charges ($39.3k), average Medicare payment ($5.7k), and total discharges (17.6k) for the period reported.

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$7.9K	$39K	$5.7K	18K

Patient Population

This DRG’s patient population skews toward an older mix with a substantial Medicare representation, though commercial payers also appear in the case mix consistent with a mixed-age population. The cohort is not exclusively Medicare-age and includes working-age individuals covered by private/commercial plans. Overall, payer mix reflects both Medicare and commercial coverage rather than being dominated solely by one sector.

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

In Alaska for DRG 176, mean allowed amounts range from 13K to 19K across payers, with Cigna at the top end (mean 19K) and Anthem and Blue Cross Blue Shield at the lower bound (mean 13K). The state exhibits a notable deviation from national averages, where national medians are generally lower; Cigna’s Alaska mean sits well above typical national medians for this DRG. See the table and chart below for payer-level detail.

Key Insights for Alaska

Cigna is the highest-paying payer in Alaska with a mean of 19K, while Anthem and Blue Cross Blue Shield are the lowest at 13K.
Alaska’s mean rates skew higher than national medians for this DRG, with Cigna notably above national medians and Anthem/Blue Cross Blue Shield clustered at a uniform lower level.

Clinical Trials

Acute anticoagulation strategy trials: randomized or pragmatic studies comparing different initial anticoagulation approaches (e.g., low-molecular-weight heparin versus direct oral anticoagulants or varying dosing/timing regimens) in hospitalized patients presenting with acute pulmonary embolism without major complications. These studies enroll adults admitted for confirmed PE who do not have life‑threatening hemodynamic instability or major comorbid complications, and they focus on early safety endpoints (bleeding) and short‑term efficacy (recurrent VTE during index hospitalization). Results are directly relevant to inpatient clinicians determining initial therapy and to payers because choices influence length of stay, need for monitoring or reversal agents, and downstream costs associated with complications.
Comparative effectiveness of inpatient diagnostic and risk‑stratification pathways: prospective cohort or cluster trials evaluating structured use of diagnostic algorithms (pretest probability scoring, D‑dimer thresholds, imaging stewardship) and validated risk scores to guide which hospitalized patients with suspected PE require advanced imaging, telemetry, or ICU observation versus standard care. These studies target patients with suspected or confirmed non‑massive PE and examine outcomes such as diagnostic yield, resource utilization (CT use, observation bed days), 30‑day adverse events, and hospital throughput. For hospitals and payers managing DRG 176 cases, evidence from this research can reduce unnecessary imaging and observation admissions, improving cost-effectiveness while maintaining patient safety.
Post‑discharge outcomes and care‑transition studies: longitudinal studies and randomized trials of discharge timing, outpatient follow‑up models, and duration/intensity of anticoagulation monitoring for patients hospitalized with PE without complications. These investigations enroll clinically stable patients being discharged from the hospital and assess readmission rates, recurrent thromboembolism, bleeding events, adherence to anticoagulation, and patient‑reported outcomes over weeks to months. Findings inform discharge planning protocols and outpatient management strategies that affect readmissions and total cost of care, making them highly pertinent to both providers optimizing transitions and payers tracking value for this DRG.

Related Codes

163-MAJOR-CHEST-PROCEDURES-WITH-MCC

Major Chest Procedures with MCC: Inpatient Reimbursement Overview

164-MAJOR-CHEST-PROCEDURES-WITH-CC

Major Chest Procedures with CC: 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

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 176

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$7.9K	$39K	$5.7K	18K

Patient Population

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Mean Rates by Payer — Alaska — DRG 176

Key Insights for Alaska

Cigna is the highest-paying payer in Alaska with a mean of 19K, while Anthem and Blue Cross Blue Shield are the lowest at 13K.
Alaska’s mean rates skew higher than national medians for this DRG, with Cigna notably above national medians and Anthem/Blue Cross Blue Shield clustered at a uniform lower level.

Clinical Trials

Acute anticoagulation strategy trials: randomized or pragmatic studies comparing different initial anticoagulation approaches (e.g., low-molecular-weight heparin versus direct oral anticoagulants or varying dosing/timing regimens) in hospitalized patients presenting with acute pulmonary embolism without major complications. These studies enroll adults admitted for confirmed PE who do not have life‑threatening hemodynamic instability or major comorbid complications, and they focus on early safety endpoints (bleeding) and short‑term efficacy (recurrent VTE during index hospitalization). Results are directly relevant to inpatient clinicians determining initial therapy and to payers because choices influence length of stay, need for monitoring or reversal agents, and downstream costs associated with complications.
Comparative effectiveness of inpatient diagnostic and risk‑stratification pathways: prospective cohort or cluster trials evaluating structured use of diagnostic algorithms (pretest probability scoring, D‑dimer thresholds, imaging stewardship) and validated risk scores to guide which hospitalized patients with suspected PE require advanced imaging, telemetry, or ICU observation versus standard care. These studies target patients with suspected or confirmed non‑massive PE and examine outcomes such as diagnostic yield, resource utilization (CT use, observation bed days), 30‑day adverse events, and hospital throughput. For hospitals and payers managing DRG 176 cases, evidence from this research can reduce unnecessary imaging and observation admissions, improving cost-effectiveness while maintaining patient safety.
Post‑discharge outcomes and care‑transition studies: longitudinal studies and randomized trials of discharge timing, outpatient follow‑up models, and duration/intensity of anticoagulation monitoring for patients hospitalized with PE without complications. These investigations enroll clinically stable patients being discharged from the hospital and assess readmission rates, recurrent thromboembolism, bleeding events, adherence to anticoagulation, and patient‑reported outcomes over weeks to months. Findings inform discharge planning protocols and outpatient management strategies that affect readmissions and total cost of care, making them highly pertinent to both providers optimizing transitions and payers tracking value for this DRG.

Related Codes

163-MAJOR-CHEST-PROCEDURES-WITH-MCC

Major Chest Procedures with MCC: Inpatient Reimbursement Overview

164-MAJOR-CHEST-PROCEDURES-WITH-CC

Major Chest Procedures with CC: 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

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.