Simple Pneumonia and Pleurisy with MCC: Inpatient Reimbursement Overview

DRG 193 addresses inpatient admissions for simple pneumonia and pleurisy accompanied by a Major Complication or Comorbidity, indicating higher clinical complexity. It matters for inpatient reimbursement because the Major Complication or Comorbidity status elevates the Diagnosis-Related Group assignment and typically increases Medicare payment to reflect greater resource utilization.

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DRG 193 Overview

DRG 193 covers inpatient admissions for simple pneumonia and pleurisy when a Major Complication or Comorbidity is present, reflecting cases with increased clinical complexity such as acute respiratory failure or severe sepsis. This Diagnosis-Related Group is important for Medicare payment because the presence of a Major Complication or Comorbidity typically triggers higher reimbursement to account for greater resource use and longer lengths of stay. Accurate documentation and coding of the Major Complication or Comorbidity directly affect payment assignment and hospital billing for these admissions. The DRG also guides case-mix measurement and hospital comparative metrics under Medicare payment systems.

National Payment Rates

Across commercial payers the observed rate range spans from about $13K (BCBS median) up to $49K (Anthem max), with payer medians clustering near $20K–$23K; the widest spread is seen with Anthem (min $390 to max $49K). See the table and chart below for payer-level percentiles and distribution details. Aetna, Cigna, Anthem, and BCBS show distinct percentile patterns reflecting differing negotiated rates.

The CMS 2023 data represent national Medicare fee-for-service inpatient payments published under the CMS Provider Utilization and Payment Data program. The table below shows average total payment ($11.5k), average submitted covered charges ($56.9k), average Medicare payment amount ($9.4k), and total discharges (128.6k).

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$11K	$57K	$9.4K	130K

Patient Population

This DRG’s population includes a mix of Medicare-age and working-age patients but skews toward Medicare-age beneficiaries given the substantial Medicare discharge volume reported nationally. Commercial payers (Aetna, Cigna, Anthem, BCBS) cover a meaningful share of working-age adults, so the overall payer mix is mixed but weighted toward Medicare-age patients. Age distribution will therefore reflect both older adults and a smaller proportion of younger, commercially insured patients.

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Alaska’s reimbursed amounts for DRG 193 range from roughly $7.5K at the low end to $56K at the high end across payers, with most payers clustering near a $20K mean while Cigna stands out around $33K. This wide range reflects a pronounced outlier in Cigna’s higher maximum and mean compared with the other state payers and with typical national levels. See the table and chart below for payer-specific distributions.

Key Insights for Alaska

Highest payer: Cigna (max $56K, mean $33K) — notably above other local payers.
Lowest payer: Anthem/Blue Cross Blue Shield (max $32K, mean $20K) — both share similar distributions and sit well below Cigna.
Meaningful deviation: Cigna’s mean ($33K) substantially exceeds the other Alaska payers’ means (~$20K), and is higher than the listed national averages, indicating a pronounced premium in the state for this DRG.

Clinical Trials

Acute antimicrobial strategy trials: randomized or pragmatic studies comparing different antibiotic regimens (choice, duration, or route of administration) in hospitalized adults with community-acquired pneumonia or pleurisy complicated by major comorbid conditions (for example, heart failure, chronic lung disease, or severe diabetes). These studies enroll patients at admission to evaluate time to clinical stability, length of stay, and in-hospital complication rates, helping determine which initial inpatient antimicrobial approaches lead to faster recovery and fewer complications. Findings are directly relevant to providers for bedside antibiotic selection and to payers because optimized regimens can shorten LOS and reduce use of escalation therapies and downstream costs.
Supportive care and respiratory management trials: comparative effectiveness or device studies examining oxygen delivery strategies, use of noninvasive ventilation, airway clearance techniques, or standardized protocols for early mobilization and pulmonary hygiene in patients hospitalized with pneumonia and pleurisy who have major comorbidities or physiologic instability. These trials typically focus on differences in need for ICU transfer, incidence of respiratory failure, length of stay, and readmission risk among subgroups such as elderly patients, those with COPD, or heart failure. Results inform inpatient care pathways and resource allocation decisions, guiding clinicians on which supportive interventions reduce complications and informing payers about interventions that may lower utilization of high-cost services.
Post-discharge outcomes and transitional care studies: cohort studies and randomized trials testing discharge planning interventions, early outpatient follow-up models, home health support, or hospitalization-to-home care bundles for survivors of pneumonia with significant comorbidities and an index hospitalization coded as Simple Pneumonia and Pleurisy with MCC. These studies measure 30-day readmission rates, post-discharge mortality, medication adherence, and functional recovery, often targeting older adults or patients with complex chronic conditions who are at high risk for readmission. This area is essential for providers to reduce avoidable returns and improve recovery, and for payers because effective transitional care can reduce costly readmissions and long post-acute service use.

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

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

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 193

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$11K	$57K	$9.4K	130K

Patient Population

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Mean Rates by Payer — Alaska — DRG 193

Key Insights for Alaska

Highest payer: Cigna (max $56K, mean $33K) — notably above other local payers.
Lowest payer: Anthem/Blue Cross Blue Shield (max $32K, mean $20K) — both share similar distributions and sit well below Cigna.
Meaningful deviation: Cigna’s mean ($33K) substantially exceeds the other Alaska payers’ means (~$20K), and is higher than the listed national averages, indicating a pronounced premium in the state for this DRG.

Clinical Trials

Acute antimicrobial strategy trials: randomized or pragmatic studies comparing different antibiotic regimens (choice, duration, or route of administration) in hospitalized adults with community-acquired pneumonia or pleurisy complicated by major comorbid conditions (for example, heart failure, chronic lung disease, or severe diabetes). These studies enroll patients at admission to evaluate time to clinical stability, length of stay, and in-hospital complication rates, helping determine which initial inpatient antimicrobial approaches lead to faster recovery and fewer complications. Findings are directly relevant to providers for bedside antibiotic selection and to payers because optimized regimens can shorten LOS and reduce use of escalation therapies and downstream costs.
Supportive care and respiratory management trials: comparative effectiveness or device studies examining oxygen delivery strategies, use of noninvasive ventilation, airway clearance techniques, or standardized protocols for early mobilization and pulmonary hygiene in patients hospitalized with pneumonia and pleurisy who have major comorbidities or physiologic instability. These trials typically focus on differences in need for ICU transfer, incidence of respiratory failure, length of stay, and readmission risk among subgroups such as elderly patients, those with COPD, or heart failure. Results inform inpatient care pathways and resource allocation decisions, guiding clinicians on which supportive interventions reduce complications and informing payers about interventions that may lower utilization of high-cost services.
Post-discharge outcomes and transitional care studies: cohort studies and randomized trials testing discharge planning interventions, early outpatient follow-up models, home health support, or hospitalization-to-home care bundles for survivors of pneumonia with significant comorbidities and an index hospitalization coded as Simple Pneumonia and Pleurisy with MCC. These studies measure 30-day readmission rates, post-discharge mortality, medication adherence, and functional recovery, often targeting older adults or patients with complex chronic conditions who are at high risk for readmission. This area is essential for providers to reduce avoidable returns and improve recovery, and for payers because effective transitional care can reduce costly readmissions and long post-acute service use.

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

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

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.