Summary & Overview

Heart Failure and Shock with MCC: Inpatient Reimbursement Overview

DRG 291 addresses heart failure and circulatory shock cases with at least one Major Complication or Comorbidity, reflecting higher clinical severity for inpatient management. It matters for inpatient reimbursement because the added severity classification increases expected resource use and Medicare payment relative to lower-severity Diagnosis-Related Group assignments.

Heart Failure and Shock with Major Complication or ComorbidityDRG Heart Failure and Shock with MCCDRG 291Diagnosis-Related GroupInpatient ReimbursementMedicareCardiologyCritical CareHospital Revenue Cycle

DRG 291 Overview

DRG 291 covers inpatient admissions for heart failure and circulatory shock when a Major Complication or Comorbidity is present, indicating higher clinical complexity and resource use. This Diagnosis-Related Group applies to patients with acute decompensated heart failure or cardiogenic, hypovolemic, or distributive shock plus at least one significant secondary condition. The presence of a Major Complication or Comorbidity increases the expected intensity of care, length of stay, and Medicare payment relative to lower-severity groups. Payers and hospital revenue cycle teams monitor this Diagnosis-Related Group because it materially affects reimbursement for inpatient episodes.

National Payment Rates

Across commercial payers the reported mean/median rates for DRG 291 range from roughly $13K (BCBS mean) up to $22K (Aetna mean), with payer medians spanning about $12K to $24K across the group; the full payer range in the benchmark table spans from a low of $370 to a high of $50K. The widest spread between minimum and maximum within a payer is seen in the Anthem data (min $390 to max $50K). Refer to the table and chart below for payer-level quartiles and distribution.

Mean Rates by Payer — National — DRG 291

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

DRG 291 payments in Alaska range from about $7.5K at the lower end to as much as $55K across payers, with state means clustered near $20K–$32K. Cigna stands out with a substantially higher median ($31K) and 75th percentile ($52K) versus other local payers, marking a clear deviation from national median levels. See the table and chart below for the full payer breakdown and distribution visualizations.

Key Insights for Alaska

Anthem is the highest-paying payer in Alaska with a 75th percentile of $32K, while Blue Cross Blue Shield (BCBS) and Anthem’s regional equivalent (ANTHEM listed twice in appendix) share the lowest observed 25th percentile at $7.5K—overall range across payers spans roughly $7.5K to $55K.
Cigna’s distribution is meaningfully higher than the other listed payers in Alaska (median $31K, 75th $52K, max $55K), representing a notable upward deviation from the national medians for Cigna and other payers.

Clinical Trials

Acute hemodynamic intervention trials: randomized or adaptive studies testing interventions delivered during the inpatient stay to rapidly stabilize patients with decompensated heart failure or cardiogenic shock (for example, device-based circulatory support strategies, vasoactive agent protocols, or early diuresis/ultrafiltration strategies). These studies enroll patients who present with severe congestion, low output states, or cardiorenal compromise and aim to measure short-term hemodynamic improvement, organ perfusion, and in-hospital complications. Results are directly relevant to hospital providers and payers because they inform which acute management approaches reduce length of stay, ICU utilization, and costly in-hospital adverse events in the DRG 291 population.
Comparative effectiveness and care pathway studies: pragmatic randomized trials or large observational comparative studies evaluating different inpatient care pathways and medication strategies for patients with heart failure and major comorbid complications (MCC), such as advanced guideline-directed medical therapy initiation/titration versus usual care, or protocols for integrated cardiology–nephrology management. These studies target typical DRG 291 patients who have multiple organ dysfunctions or serious comorbidities that complicate therapy, and they assess outcomes like readmission rates, composite morbidity, and total cost of care over 30–90 days. Findings help clinicians and payers decide which inpatient workflows and therapy sequences provide the best balance of clinical benefit and resource use for high-acuity heart failure admissions.
Transitional care, post-discharge outcomes, and readmission-reduction trials: randomized or cohort studies of structured discharge interventions, early outpatient follow-up, remote monitoring, or home-based care for patients recently discharged after an admission for heart failure and shock with MCC. These trials enroll high-risk DRG 291 survivors characterized by frailty, polypharmacy, renal dysfunction, or prior readmissions and measure 30- and 90-day readmission, mortality, medication adherence, and total post-discharge costs. This research is crucial for payers and health systems seeking evidence-based strategies to reduce costly readmissions, improve long-term outcomes, and optimize post-acute resource allocation for this high-risk group.

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$12K	$54K	$9.6K	320K

Acute hemodynamic intervention trials: randomized or adaptive studies testing interventions delivered during the inpatient stay to rapidly stabilize patients with decompensated heart failure or cardiogenic shock (for example, device-based circulatory support strategies, vasoactive agent protocols, or early diuresis/ultrafiltration strategies). These studies enroll patients who present with severe congestion, low output states, or cardiorenal compromise and aim to measure short-term hemodynamic improvement, organ perfusion, and in-hospital complications. Results are directly relevant to hospital providers and payers because they inform which acute management approaches reduce length of stay, ICU utilization, and costly in-hospital adverse events in the DRG 291 population.
Comparative effectiveness and care pathway studies: pragmatic randomized trials or large observational comparative studies evaluating different inpatient care pathways and medication strategies for patients with heart failure and major comorbid complications (MCC), such as advanced guideline-directed medical therapy initiation/titration versus usual care, or protocols for integrated cardiology–nephrology management. These studies target typical DRG 291 patients who have multiple organ dysfunctions or serious comorbidities that complicate therapy, and they assess outcomes like readmission rates, composite morbidity, and total cost of care over 30–90 days. Findings help clinicians and payers decide which inpatient workflows and therapy sequences provide the best balance of clinical benefit and resource use for high-acuity heart failure admissions.
Transitional care, post-discharge outcomes, and readmission-reduction trials: randomized or cohort studies of structured discharge interventions, early outpatient follow-up, remote monitoring, or home-based care for patients recently discharged after an admission for heart failure and shock with MCC. These trials enroll high-risk DRG 291 survivors characterized by frailty, polypharmacy, renal dysfunction, or prior readmissions and measure 30- and 90-day readmission, mortality, medication adherence, and total post-discharge costs. This research is crucial for payers and health systems seeking evidence-based strategies to reduce costly readmissions, improve long-term outcomes, and optimize post-acute resource allocation for this high-risk group.

OpenPayer

Summary & Overview

Heart Failure and Shock with MCC: Inpatient Reimbursement Overview

DRG 291 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