Hepatobiliary Diagnostic Procedures with CC: Inpatient Reimbursement Overview

DRG 421 encompasses inpatient hepatobiliary diagnostic procedures with a Complication or Comorbidity, including diagnostic endoscopic and percutaneous biliary interventions. This classification matters for inpatient reimbursement because it groups cases by expected resource use and adjusts Medicare payment for procedural complexity and comorbid conditions.

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DRG 421 Overview

DRG 421 covers inpatient cases centered on hepatobiliary diagnostic procedures, such as diagnostic endoscopic retrograde cholangiopancreatography, percutaneous biliary drainage, and related operative explorations when a Complication or Comorbidity is present. This Diagnosis-Related Group groups patients by resource intensity driven by the diagnostic procedures and the added complexity from Complication or Comorbidity. It matters for Medicare payment because classification into DRG 421 affects hospital reimbursement under the inpatient prospective payment system by reflecting procedure-related resource use and comorbid condition impact. Accurate DRG assignment influences payment level and hospital billing classification within Medicare.

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Hepatobiliary Diagnostic Procedures with CC: Inpatient Reimbursement Overview

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DRG 421 Overview

National Payment Rates

Across commercial payers the rate range runs roughly from $370 (BCBS min) up to $63K (Anthem max), with mean/median payer benchmarks clustered in the mid-to-high tens of thousands. The widest spread is seen with Anthem, which shows the largest max ($63K) relative to its min. See the payer table and the chart below for full distribution and percentile detail.

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 421. Values reflect national aggregates for Medicare FFS in 2023.

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$18K	$87K	$14K	550

Patient Population

This DRG’s inpatient population skews toward older adults and Medicare-age beneficiaries rather than primarily working-age patients. Commercial payers still cover a portion of cases, indicating a mixed but Medicare-leaning population. The distribution suggests Medicare FFS comprises a substantial share of discharges compared with private/commercial payers.

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Alaska’s DRG 421 rates span from $27K (Blue Cross Blue Shield and Anthem) up to $42K (Cigna), a relatively tight range dominated by a single higher outlier. Cigna’s mean of $42K stands out as notably above national averages, while Blue Cross Blue Shield and Anthem cluster at the state low of $27K. See the table and chart below for payer-level detail.

Key Insights for Alaska

Cigna is the highest-paying payer in Alaska with a mean of $42K, while Blue Cross Blue Shield is the lowest at $27K.
Anthem in Alaska aligns with BCBS at $27K, producing a narrow state range compared with national variation; Cigna’s $42K mean is meaningfully above national means.

Clinical Trials

Studies evaluating diagnostic accuracy and optimization of hepatobiliary imaging pathways in hospitalized patients with suspected biliary obstruction or acute cholangitis. These prospective diagnostic cohort studies enroll adults presenting with jaundice, right upper quadrant pain, abnormal liver function tests, or suspected bile duct stones, comparing modalities (e.g., ultrasound, MRCP, endoscopic cholangiography) and timing of procedures to establish sensitivity, specificity, and time-to-diagnosis metrics. Results inform clinical pathways that can reduce unnecessary procedures, shorten length of stay, and help payers and providers target resource use for patients assigned to this DRG.
Randomized or pragmatic comparative effectiveness trials of endoscopic versus percutaneous biliary drainage approaches for patients with complicated obstructive hepatobiliary disease and coexisting comorbidities. These trials focus on inpatients with clinically significant obstruction and CC-level complications (sepsis, coagulopathy, or advanced liver disease), measuring technical success, complication rates, need for reintervention, and short-term functional outcomes. Findings guide procedural selection and risk stratification strategies that affect hospital costs, readmission risk, and reimbursement decisions for DRG 421 cases.
Observational cohort and quality-outcomes research examining post-discharge trajectories, readmissions, and long-term liver-related outcomes after hepatobiliary diagnostic procedures in patients with complex comorbidities. These studies track patients with CCs (e.g., chronic liver disease, heart failure, diabetes) to identify predictors of 30- and 90-day readmission, post-procedural infections, or progression to biliary complications, and assess the impact of discharge planning and outpatient follow-up. Insights support payer and provider efforts to design transitional care interventions, bundle payments, and case management programs to reduce avoidable utilization for this DRG.

Pancreas, Liver and Shunt Procedures with MCC: Inpatient Reimbursement Overview

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Pancreas, Liver and Shunt Procedures with CC: Inpatient Reimbursement Overview

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Pancreas, Liver and Shunt Procedures without CC/MCC: Inpatient Reimbursement Overview

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Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. with MCC: Inpatient Reimbursement Overview

409-BILIARY-TRACT-PROCEDURES-EXCEPT-ONLY-CHOLECYSTECTOMY-WITH-OR-WITHOUT-C-D-E-WITH-CC

Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. with CC: Inpatient Reimbursement Overview

410-BILIARY-TRACT-PROCEDURES-EXCEPT-ONLY-CHOLECYSTECTOMY-WITH-OR-WITHOUT-C-D-E-WITHOUT-CC-MCC

Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E.: Inpatient Reimbursement Overview

411-CHOLECYSTECTOMY-WITH-C-D-E-WITH-MCC

Cholecystectomy with C.D.E. with MCC: Inpatient Reimbursement Overview

412-CHOLECYSTECTOMY-WITH-C-D-E-WITH-CC

Cholecystectomy with Common Duct Exploration with Complication or Comorbidity: Inpatient Reimbursement Overview

413-CHOLECYSTECTOMY-WITH-C-D-E-WITHOUT-CC-MCC

Cholecystectomy with C.D.E. without CC/MCC: Inpatient Reimbursement Overview

414-CHOLECYSTECTOMY-EXCEPT-BY-LAPAROSCOPE-WITHOUT-C-D-E-WITH-MCC

Cholecystectomy Except by Laparoscope without C.D.E. with MCC: Inpatient Reimbursement Overview

Showing 1–10 of 35

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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Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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National Payment Rates

Mean Rates by Payer — National — DRG 421

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$18K	$87K	$14K	550

Patient Population

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Mean Rates by Payer — Alaska — DRG 421

Key Insights for Alaska

Cigna is the highest-paying payer in Alaska with a mean of $42K, while Blue Cross Blue Shield is the lowest at $27K.
Anthem in Alaska aligns with BCBS at $27K, producing a narrow state range compared with national variation; Cigna’s $42K mean is meaningfully above national means.

Clinical Trials

Studies evaluating diagnostic accuracy and optimization of hepatobiliary imaging pathways in hospitalized patients with suspected biliary obstruction or acute cholangitis. These prospective diagnostic cohort studies enroll adults presenting with jaundice, right upper quadrant pain, abnormal liver function tests, or suspected bile duct stones, comparing modalities (e.g., ultrasound, MRCP, endoscopic cholangiography) and timing of procedures to establish sensitivity, specificity, and time-to-diagnosis metrics. Results inform clinical pathways that can reduce unnecessary procedures, shorten length of stay, and help payers and providers target resource use for patients assigned to this DRG.
Randomized or pragmatic comparative effectiveness trials of endoscopic versus percutaneous biliary drainage approaches for patients with complicated obstructive hepatobiliary disease and coexisting comorbidities. These trials focus on inpatients with clinically significant obstruction and CC-level complications (sepsis, coagulopathy, or advanced liver disease), measuring technical success, complication rates, need for reintervention, and short-term functional outcomes. Findings guide procedural selection and risk stratification strategies that affect hospital costs, readmission risk, and reimbursement decisions for DRG 421 cases.
Observational cohort and quality-outcomes research examining post-discharge trajectories, readmissions, and long-term liver-related outcomes after hepatobiliary diagnostic procedures in patients with complex comorbidities. These studies track patients with CCs (e.g., chronic liver disease, heart failure, diabetes) to identify predictors of 30- and 90-day readmission, post-procedural infections, or progression to biliary complications, and assess the impact of discharge planning and outpatient follow-up. Insights support payer and provider efforts to design transitional care interventions, bundle payments, and case management programs to reduce avoidable utilization for this DRG.

Pancreas, Liver and Shunt Procedures with MCC: Inpatient Reimbursement Overview

406-PANCREAS-LIVER-AND-SHUNT-PROCEDURES-WITH-CC

Pancreas, Liver and Shunt Procedures with CC: Inpatient Reimbursement Overview

407-PANCREAS-LIVER-AND-SHUNT-PROCEDURES-WITHOUT-CC-MCC

Pancreas, Liver and Shunt Procedures without CC/MCC: Inpatient Reimbursement Overview

408-BILIARY-TRACT-PROCEDURES-EXCEPT-ONLY-CHOLECYSTECTOMY-WITH-OR-WITHOUT-C-D-E-WITH-MCC

Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. with MCC: Inpatient Reimbursement Overview

409-BILIARY-TRACT-PROCEDURES-EXCEPT-ONLY-CHOLECYSTECTOMY-WITH-OR-WITHOUT-C-D-E-WITH-CC

Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E. with CC: Inpatient Reimbursement Overview

410-BILIARY-TRACT-PROCEDURES-EXCEPT-ONLY-CHOLECYSTECTOMY-WITH-OR-WITHOUT-C-D-E-WITHOUT-CC-MCC

Biliary Tract Procedures Except Only Cholecystectomy with or without C.D.E.: Inpatient Reimbursement Overview

411-CHOLECYSTECTOMY-WITH-C-D-E-WITH-MCC

Cholecystectomy with C.D.E. with MCC: Inpatient Reimbursement Overview

412-CHOLECYSTECTOMY-WITH-C-D-E-WITH-CC

Cholecystectomy with Common Duct Exploration with Complication or Comorbidity: Inpatient Reimbursement Overview

413-CHOLECYSTECTOMY-WITH-C-D-E-WITHOUT-CC-MCC

Cholecystectomy with C.D.E. without CC/MCC: Inpatient Reimbursement Overview

414-CHOLECYSTECTOMY-EXCEPT-BY-LAPAROSCOPE-WITHOUT-C-D-E-WITH-MCC

Cholecystectomy Except by Laparoscope without C.D.E. with MCC: Inpatient Reimbursement Overview

Showing 1–10 of 35

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.

OpenPayer

Hepatobiliary Diagnostic Procedures with CC: Inpatient Reimbursement Overview

Sign up for drg 421 policy alerts

DRG 421 Overview

OpenPayer

Hepatobiliary Diagnostic Procedures with CC: Inpatient Reimbursement Overview

Sign up for drg 421 policy alerts

DRG 421 Overview

National Payment Rates

Patient Population

State Payment Rates

Alaska Benchmarks

Key Insights for Alaska

Clinical Trials

Related Codes

References

National Payment Rates

Patient Population

State Payment Rates

Alaska Benchmarks

Key Insights for Alaska

Clinical Trials

Related Codes

References