Cardiac Valve and Other Major Cardiothoracic Procedures DRG Reimbursement

Summary & Overview

Cardiac Valve and Other Major Cardiothoracic Procedures with MCC: Inpatient Reimbursement Overview

DRG 219 encompasses cardiac valve and other major cardiothoracic procedures without cardiac catheterization when a Major Complication or Comorbidity is present, covering complex surgical admissions with significant additional diagnoses. This Diagnosis-Related Group matters for inpatient reimbursement because the Major Complication or Comorbidity status increases expected resource consumption and thus influences Medicare payment levels.

Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCCDRG Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCCDRG 219Diagnosis-Related GroupInpatient ReimbursementMedicareCardiothoracic SurgeryHeart Valve ReplacementValve RepairHospital Billing

DRG 219 Overview

DRG 219 covers hospital admissions for cardiac valve and other major cardiothoracic procedures performed without cardiac catheterization when a Major Complication or Comorbidity is present. Typical cases include valve repair or replacement and major mediastinal or thoracic operations complicated by significant comorbid conditions that increase resource use. This Diagnosis-Related Group matters for Medicare inpatient payment because the presence of a Major Complication or Comorbidity elevates the reimbursement relative to lower-severity groups, reflecting higher expected costs and length of stay. Accurate coding of principal procedures and Major Complication or Comorbidity diagnoses directly affects assignment to this Diagnosis-Related Group and resulting payment.

National Payment Rates

Payer-negotiated rates for DRG 219 span a wide range across commercial insurers, from as low as $64K (reported by Cigna) up to $280K (Anthem). The mean contractual rates cluster around $68K–$120K depending on payer, with Anthem showing the widest spread between its minimum and maximum values. See the table and chart below for payer-level detail and percentile distributions.

Mean Rates by Payer — National — DRG 219

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, average submitted covered charges, average Medicare payment amount, and total discharges for DRG 219. These values reflect national FFS Medicare activity for the reporting year.

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Payer-reported means in Alaska for DRG 219 span from $120K to $180K, with Blue Cross Blue Shield and Anthem at the low end and Cigna at the high end. The range is relatively modest but Cigna’s $180K stands out as above common national medians (~$120K). See the table and chart below for payer-specific distributions.

Key Insights for Alaska

Cigna is the highest-paying payer in Alaska with a mean of $180K, while Blue Cross Blue Shield and Anthem both report the lowest mean at $120K.
Alaska’s payer mean range ($120K–$180K) is narrower but shifted higher than several national medians; Cigna’s $180K notably exceeds typical national medians around $120K, representing the most meaningful deviation.

Clinical Trials

Acute perioperative intervention trials: randomized or pragmatic studies testing intraoperative or immediate post-operative strategies (for example, myocardial protection techniques, transfusion thresholds, or hemodynamic management protocols) in adult patients undergoing major cardiothoracic operations for valvular disease or complex cardiac surgery with high acuity and complications (the MCC population). These studies focus on short-term endpoints such as operative mortality, major morbidity (stroke, renal failure, prolonged ventilation), and ICU length of stay to identify interventions that reduce immediate complications. Results are directly relevant to providers and payers because reductions in perioperative adverse events and ICU utilization can improve patient outcomes and substantially lower episode-of-care costs for this high-resource DRG.
Comparative effectiveness studies of surgical approaches and timing: observational cohort studies or randomized trials comparing valve repair versus replacement, different prosthesis types, or staged versus immediate combined procedures in patients with complex valvular pathology and significant comorbidities (the subgroup with MCC). These investigations evaluate mid-term outcomes such as reoperation rates, functional status, readmissions, and cost-effectiveness across heterogeneous high-risk patients to determine which approaches provide the best trade-off of durability and resource use. Such evidence helps clinicians tailor surgical plans for high-risk cases and helps payers and hospital administrators forecast resource needs and justify coverage or care pathways for expensive procedures.
Post-discharge outcomes and care-transition research: prospective cohort studies and quality-improvement trials assessing multidisciplinary discharge planning, early outpatient surveillance, rehabilitation, and readmission-reduction bundles for survivors of major cardiothoracic surgery with complications. These studies enroll patients discharged after complex valve or cardiothoracic procedures complicated by major comorbid events and measure 30–90 day readmissions, functional recovery, medication adherence, and total post-acute costs to identify effective strategies for reducing downstream utilization. Findings inform clinicians and payers about interventions that improve recovery, lower avoidable readmissions, and shift costly readmission or prolonged SNF use into more efficient outpatient management.

Cardiac Arrest, Unexplained without CC/MCC: Inpatient Reimbursement Overview

272-OTHER-MAJOR-CARDIOVASCULAR-PROCEDURES-WITHOUT-CC-MCC

Other Major Cardiovascular Procedures without CC/MCC: Inpatient Reimbursement Overview

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Aortic and Heart Assist Procedures Except Pulsation Balloon with MCC: Inpatient Reimbursement Overview

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Percutaneous Cardiovascular Procedures without Intraluminal Device with MCC: Inpatient Reimbursement Overview

236-CORONARY-BYPASS-WITHOUT-CARDIAC-CATHETERIZATION-WITHOUT-MCC

Coronary Bypass without Cardiac Catheterization without MCC: Inpatient Reimbursement Overview

258-CARDIAC-PACEMAKER-DEVICE-REPLACEMENT-WITH-MCC

Cardiac Pacemaker Device Replacement with MCC: Inpatient Reimbursement Overview

311-ANGINA-PECTORIS

Angina Pectoris: Inpatient Reimbursement Overview

281-ACUTE-MYOCARDIAL-INFARCTION-DISCHARGED-ALIVE-WITH-CC

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271-OTHER-MAJOR-CARDIOVASCULAR-PROCEDURES-WITH-CC

Other Major Cardiovascular Procedures with CC: Inpatient Reimbursement Overview

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Cardiac Defibrillator Implant with MCC or Carotid Sinus Neurostimulator: Inpatient Reimbursement Overview

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OpenPayer

Summary & Overview

Cardiac Valve and Other Major Cardiothoracic Procedures with MCC: Inpatient Reimbursement Overview

DRG 219 Overview

National Payment Rates

State Payment Rates

Alaska Benchmarks

Key Insights for Alaska

Clinical Trials

Related Codes

Patient Population

State Payment Rates

Alaska Benchmarks

Key Insights for Alaska

Clinical Trials

Related Codes