Simple Pneumonia and Pleurisy without CC/MCC DRG Reimbursement

Summary & Overview

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

DRG 195 pertains to hospital stays for simple pneumonia and pleurisy without Complication or Comorbidity or Major Complication or Comorbidity and defines the clinical scope for uncomplicated respiratory infection admissions. This grouping matters for inpatient reimbursement because it determines the Centers for Medicare & Medicaid Services payment weight applied to such cases and influences hospital billing and resource allocation.

Simple Pneumonia and PleurisyDRG Simple Pneumonia and Pleurisy without CC/MCCDRG 195Diagnosis-Related GroupInpatient ReimbursementMedicarePulmonologyInternal MedicineHospital MedicineAcute Care

DRG 195 Overview

DRG 195 covers hospital admissions for simple pneumonia and pleurisy without a Complication or Comorbidity or Major Complication or Comorbidity. This Diagnosis-Related Group applies when patients receive inpatient care for uncomplicated lower respiratory infections that do not trigger higher-severity groupings. It matters for Centers for Medicare & Medicaid Services payment because it establishes the base Medicare inpatient reimbursement rate for these straightforward pneumonia admissions. Hospitals use this grouping to classify cases that typically require medical management without intensive resource use.

National Payment Rates

Across commercial payers the observed rate range runs roughly from about $6.5K (BCBS mean) up to about $11K (Aetna mean), with Anthem and Cigna clustering near $9.9K–$10K. The widest spread between payer means is roughly $4.5K (Aetna vs BCBS). Refer to the payer table and the chart below for payer-level percentiles and distributions.

Mean Rates by Payer — National — DRG 195

The CMS 2023 data represent national Medicare fee-for-service inpatient payments reported under the CMS Provider Utilization and Payment Data program. The table below shows average total payment ($6.1k), average submitted covered charges ($28.9k), average Medicare payment amount ($4.2k), and total discharges (7.9k).

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Alaska’s DRG 195 mean payments span from $9.8K (Anthem and Blue Cross Blue Shield) up to $15K (Cigna), indicating a roughly $5.2K spread across payers. Cigna’s mean sits noticeably higher than the other listed payers and above several national median references. See the table and chart below for payer-level detail and distribution.

Key Insights for Alaska

Highest payer: Cigna (mean $15K) is the top-paying payer in Alaska; lowest payers: Anthem and BCBS (both mean $9.8K).
Alaska’s payer means range is relatively wide (~$9.8K to $15K), with Cigna notably above the other local payers and above typical national medians for several payers.

Clinical Trials

Acute antimicrobial strategy trials: randomized studies comparing short-course versus standard-duration antibiotic regimens or oral step-down strategies in hospitalized adults with uncomplicated community-acquired pneumonia without major comorbidities. These trials enroll patients admitted for acute management under DRG 195 criteria to evaluate time to clinical stabilization, length of stay, readmission rates, and antibiotic-related adverse events. Results are relevant to providers and payers because optimizing antibiotic duration and route of administration can reduce inpatient days, lower pharmacy costs, and minimize complications that drive downstream utilization.
Comparative effectiveness and care pathway studies in inpatient management: pragmatic trials or observational comparative studies evaluating different evidence-based care pathways (for example, rapid diagnosis/triage protocols, early mobilization and standardized oxygen therapy, or bundled clinical order sets) for otherwise uncomplicated pneumonia and pleurisy. These studies focus on typical adult inpatients without CC/MCC to measure process metrics (time to first antibiotic, length of stay), clinical outcomes, and resource use across hospitals. Findings inform clinicians and payers about which practical inpatient workflows produce safe, cost-effective care and reduce unwarranted variation in DRG 195 case management.
Post-discharge outcomes and transitional care research: cohort studies or randomized interventions testing discharge planning, follow-up telephone or clinic visits, and home health supports aimed at preventing readmission and monitoring recovery in patients discharged after simple pneumonia. These trials target the typical DRG 195 population at risk for early return visits due to treatment failure, medication issues, or social determinants of health that affect adherence. Understanding which post-discharge supports reduce 30-day readmissions and emergency visits helps payers and health systems allocate transitional care resources efficiently and improve overall episode-of-care value.

Related Codes

187-PLEURAL-EFFUSION-WITH-CC

Pleural Effusion with CC: Inpatient Reimbursement Overview

201-PNEUMOTHORAX-WITHOUT-CC-MCC

Pneumothorax without CC/MCC: Inpatient Reimbursement Overview

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

Respiratory Infections and Inflammations with MCC: Inpatient Reimbursement Overview

179-RESPIRATORY-INFECTIONS-AND-INFLAMMATIONS-WITHOUT-CC-MCC

Respiratory Infections and Inflammations without CC/MCC: Inpatient Reimbursement Overview

188-PLEURAL-EFFUSION-WITHOUT-CC-MCC

Pleural Effusion without CC/MCC: Inpatient Reimbursement Overview

192-CHRONIC-OBSTRUCTIVE-PULMONARY-DISEASE-WITHOUT-CC-MCC

Chronic Obstructive Pulmonary Disease without CC/MCC: Inpatient Reimbursement Overview

163-MAJOR-CHEST-PROCEDURES-WITH-MCC

Major Chest Procedures with MCC: Inpatient Reimbursement Overview

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

Chronic Obstructive Pulmonary Disease with CC: Inpatient Reimbursement Overview

203-BRONCHITIS-AND-ASTHMA-WITHOUT-CC-MCC

Bronchitis and Asthma without CC/MCC: Inpatient Reimbursement Overview

202-BRONCHITIS-AND-ASTHMA-WITH-CC-MCC

Bronchitis and Asthma with CC/MCC: Inpatient Reimbursement Overview

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Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$6.1K	$29K	$4.2K	7.9K

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Mean Rates by Payer — Alaska — DRG 195

Key Insights for Alaska

Highest payer: Cigna (mean $15K) is the top-paying payer in Alaska; lowest payers: Anthem and BCBS (both mean $9.8K).
Alaska’s payer means range is relatively wide (~$9.8K to $15K), with Cigna notably above the other local payers and above typical national medians for several payers.

Clinical Trials

Acute antimicrobial strategy trials: randomized studies comparing short-course versus standard-duration antibiotic regimens or oral step-down strategies in hospitalized adults with uncomplicated community-acquired pneumonia without major comorbidities. These trials enroll patients admitted for acute management under DRG 195 criteria to evaluate time to clinical stabilization, length of stay, readmission rates, and antibiotic-related adverse events. Results are relevant to providers and payers because optimizing antibiotic duration and route of administration can reduce inpatient days, lower pharmacy costs, and minimize complications that drive downstream utilization.
Comparative effectiveness and care pathway studies in inpatient management: pragmatic trials or observational comparative studies evaluating different evidence-based care pathways (for example, rapid diagnosis/triage protocols, early mobilization and standardized oxygen therapy, or bundled clinical order sets) for otherwise uncomplicated pneumonia and pleurisy. These studies focus on typical adult inpatients without CC/MCC to measure process metrics (time to first antibiotic, length of stay), clinical outcomes, and resource use across hospitals. Findings inform clinicians and payers about which practical inpatient workflows produce safe, cost-effective care and reduce unwarranted variation in DRG 195 case management.
Post-discharge outcomes and transitional care research: cohort studies or randomized interventions testing discharge planning, follow-up telephone or clinic visits, and home health supports aimed at preventing readmission and monitoring recovery in patients discharged after simple pneumonia. These trials target the typical DRG 195 population at risk for early return visits due to treatment failure, medication issues, or social determinants of health that affect adherence. Understanding which post-discharge supports reduce 30-day readmissions and emergency visits helps payers and health systems allocate transitional care resources efficiently and improve overall episode-of-care value.