Pulmonary Embolism without MCC DRG Reimbursement Guide

Summary & Overview

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.

Pulmonary EmbolismDRG Pulmonary Embolism without MCCDRG 176Diagnosis-Related GroupInpatient ReimbursementMedicareHospital MedicinePulmonologyAnticoagulationThromboembolism

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.

Mean Rates by Payer — National — DRG 176

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.

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

201-PNEUMOTHORAX-WITHOUT-CC-MCC

Pneumothorax without CC/MCC: Inpatient Reimbursement Overview

205-OTHER-RESPIRATORY-SYSTEM-DIAGNOSES-WITH-MCC

Other Respiratory System Diagnoses with MCC: Inpatient Reimbursement Overview

193-SIMPLE-PNEUMONIA-AND-PLEURISY-WITH-MCC

Simple Pneumonia and Pleurisy with MCC: Inpatient Reimbursement Overview

191-CHRONIC-OBSTRUCTIVE-PULMONARY-DISEASE-WITH-CC

Chronic Obstructive Pulmonary Disease with CC: Inpatient Reimbursement Overview

208-RESPIRATORY-SYSTEM-DIAGNOSIS-WITH-VENTILATOR-SUPPORT-96-HOURS

Respiratory System Diagnosis with Ventilator Support <=96 Hours: Inpatient Reimbursement Overview

190-CHRONIC-OBSTRUCTIVE-PULMONARY-DISEASE-WITH-MCC

Chronic Obstructive Pulmonary Disease with MCC: Inpatient Reimbursement Overview

187-PLEURAL-EFFUSION-WITH-CC

Pleural Effusion with CC: Inpatient Reimbursement Overview

180-RESPIRATORY-NEOPLASMS-WITH-MCC

Respiratory Neoplasms with MCC: Inpatient Reimbursement Overview

207-RESPIRATORY-SYSTEM-DIAGNOSIS-WITH-VENTILATOR-SUPPORT-96-HOURS

Respiratory System Diagnosis with Ventilator Support >96 Hours: Inpatient Reimbursement Overview

195-SIMPLE-PNEUMONIA-AND-PLEURISY-WITHOUT-CC-MCC

Simple Pneumonia and Pleurisy without CC/MCC: Inpatient Reimbursement Overview

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

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.