Heart Failure and Shock with CC DRG Reimbursement Guide

Summary & Overview

Heart Failure and Shock with CC: Inpatient Reimbursement Overview

DRG 292 addresses inpatient admissions for heart failure and shock when a Complication or Comorbidity is present, capturing cases with increased clinical complexity. Assigning this Diagnosis-Related Group affects Medicare reimbursement because Complications or Comorbidities raise expected resource use and the Diagnosis-Related Group relative weight for payment.

Heart FailureDRG Heart Failure and Shock with CCDRG 292Diagnosis-Related GroupInpatient ReimbursementMedicareCardiologyCritical CareHospital CodingClinical Documentation

DRG 292 Overview

DRG 292 covers hospital admissions for heart failure and shock when a Complication or Comorbidity is present. This grouping includes patients with acute decompensated heart failure, cardiogenic shock with an associated Complication or Comorbidity, and related treatments such as diuresis, inotropic support, or hemodynamic monitoring. It matters for Medicare payment because the presence of Complications or Comorbidities increases resource use and drives higher Diagnosis-Related Group relative weights used in inpatient reimbursement. Accurate coding of the principal diagnosis and associated Complication or Comorbidity is essential for correct Medicare Severity Diagnosis-Related Group assignment.

National Payment Rates

Payer rates for DRG 292 range from about $8.5K (BCBS mean) up to $15K (Aetna mean), with Anthem and Cigna clustering near $13–14K; the widest mean spread between payers is roughly $6.5K. See the table and chart below for payer-specific percentiles and distributional detail. Payer variability is visible across the 25th–75th percentiles in the accompanying visuals.

Mean Rates by Payer — National — DRG 292

The CMS 2023 data reflect national Medicare fee-for-service inpatient payments reported 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 292. Values summarize national Medicare payments and volumes for the reporting year.

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

In Alaska for DRG 292 (Heart Failure and Shock with CC), payer rates range narrowly by mean from 13K to 20K across local payers, with Anthem, Blue Cross Blue Shield, and BCBS-centered plans clustering at 13K while Cigna’s mean sits at 20K and exhibits the largest min–max spread. The most notable deviation from national averages is Cigna’s higher mean and wide max of 34K compared with national Cigna centering near the mid-teens. See the table and chart below for detailed percentile and range values.

Key Insights for Alaska

Anthem is the highest paying payer in Alaska at a mean of 13K, while Blue Cross Blue Shield is the lowest payer at a mean of 13K — overall payer means in the state are tightly clustered around 13K.
Cigna shows the widest internal spread (min 11K, max 34K, mean 20K), representing the most meaningful deviation from national patterns where Cigna’s mean is higher regionally; this suggests greater variability in negotiated rates for Cigna in Alaska compared with the other local payers.

Clinical Trials

Acute hemodynamic intervention trials: randomized or controlled studies testing short-term interventions delivered during the hospitalization for heart failure or cardiogenic shock (for example, novel inotropes, vasodilators, or mechanical circulatory support strategies) targeted to patients with decompensated heart failure and objective evidence of hypoperfusion or congestion. These trials enroll patients during the index inpatient stay and measure time‑to‑stabilization, organ perfusion markers, and in‑hospital mortality and complications. Results inform hospital-level treatment algorithms, affect resource use in the acute care episode, and are directly relevant to payers because they can change lengths of stay, ICU utilization, and costs associated with high-acuity admissions in this DRG.
Comparative effectiveness and management strategy studies: pragmatic randomized or observational studies comparing guideline-directed medical therapy pathways, diuretic strategies (e.g., bolus versus continuous infusion, high‑dose versus stepped dosing), or multidisciplinary care bundles for patients admitted with heart failure and a complication or comorbidity (the CC in this DRG). These studies commonly enroll heterogeneous inpatient populations including older adults with renal dysfunction, diabetes, or pulmonary disease, and evaluate outcomes such as readmission, in‑hospital adverse events, and transitions to outpatient care. Findings are important to clinicians and hospital administrators for optimizing inpatient protocols and to payers for identifying approaches that reduce avoidable rehospitalization and total cost of care across the episode.
Post-discharge outcomes and transitional-care trials: randomized trials and prospective cohorts testing discharge planning interventions, early post-discharge follow-up, telemonitoring, or disease‑management programs specifically for patients recently hospitalized with heart failure or shock who have at least one complicating condition. These studies focus on 30‑ to 180‑day readmission rates, medication adherence, mortality, and patient‑reported outcomes in a high‑risk subgroup that often drives readmission metrics and bundled payment performance. Evidence from these trials guides investments in transitional-care teams and remote monitoring services that can improve quality metrics and reduce downstream costs for payers managing beneficiaries coded to this DRG.

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Summary & Overview

Heart Failure and Shock with CC: Inpatient Reimbursement Overview

DRG 292 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