Major Hip and Knee Joint Replacement or Reattachment: Inpatient Reimbursement Overview

DRG 469 pertains to major hip and knee joint replacement or reattachment of the lower extremity with a Major Complication or Comorbidity, and includes total ankle replacement when classified at this severity level. This Diagnosis-Related Group matters for inpatient reimbursement because it reflects higher resource consumption and drives increased Medicare Severity Diagnosis-Related Group payments for complex orthopedic hospitalizations.

Customize your policy alerts

Sign up for drg 469 policy alerts

Get alerted when payer policies referencing 469 are released or updated.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

DRG 469 Overview

DRG 469 covers major hip and knee joint replacement procedures and reattachment of the lower extremity when a Major Complication or Comorbidity is present, and includes total ankle replacement cases that meet similar resource intensity. This Diagnosis-Related Group groups inpatient stays by high-cost orthopedic procedures with significant perioperative complexity and comorbid conditions. It matters for Medicare payment because cases assigned here drive higher Medicare Severity Diagnosis-Related Group reimbursements to reflect increased resource use, longer lengths of stay, and added care needs. Accurate clinical documentation and coding determine assignment to this Diagnosis-Related Group and associated payment.

Explore openpayer tools

View all tools

Major Hip and Knee Joint Replacement or Reattachment: Inpatient Reimbursement Overview

Customize your policy alerts

Sign up for drg 469 policy alerts

Get alerted when payer policies referencing 469 are released or updated.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

DRG 469 Overview

National Payment Rates

Across commercial payers, negotiated rates for DRG 469 range widely from about $27K (UHC) up to $110K (Anthem), with most payers clustering between roughly $41K and $50K; the widest spread is between UHC at $27K and Anthem at $110K. See the table and chart below for payer-level percentiles and distributions including BCBS, Aetna, Cigna, Anthem, and UHC.

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 ($28.5k), average submitted covered charges ($138.8k), average Medicare payment amount ($24.8k), and total discharges (5.7k).

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$28K	$140K	$25K	5.7K

Patient Population

This DRG’s population includes a mix of Medicare-age and working-age patients, but payment datasets and utilization tend to be weighted toward Medicare beneficiaries given higher representation in inpatient claims. Commercial payers also cover a meaningful portion of cases, so the overall population is mixed rather than exclusively Medicare-age or exclusively working-age. Payer mix therefore reflects both Medicare fee-for-service and private/commercial coverage.

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

DRG 469 reimbursement in Alaska spans from a low floor of $7.5K (Anthem and BCBS p25/min) up to a high of $130K (Cigna max), with payer medians clustering at $47K for Anthem/BCBS and $72K for Cigna. The most notable deviation from national averages is Cigna’s elevated median and maximum, which exceed typical national medians, while Anthem and BCBS present an unusually wide range that includes very low values. See the table and chart below for detailed distributions by payer.

Key Insights for Alaska

Highest payer: Cigna (median $72K; max $130K) — notably above national medians for multiple payers, indicating a higher ceiling in AK.
Lowest payers: Anthem and BCBS (median $47K; min $7.5K) — both show a wide low-end floor down to $7.5K, which is meaningfully lower than typical national p25 values.
Meaningful deviation: Cigna’s median and max are substantially higher than national medians, while Anthem/BCBS exhibit a much wider range with a very low p25 compared with national benchmarks.

Clinical Trials

Perioperative optimization and complication-prevention trials: These studies evaluate interventions delivered in the immediate preoperative and inpatient periods—such as enhanced prehabilitation protocols, multimodal pain control regimens, thromboprophylaxis strategies, and infection-prevention bundles—for patients undergoing major hip or knee arthroplasty or lower-extremity reattachment with major comorbidities (MCC). The population typically includes older adults with cardiovascular disease, diabetes, obesity, or renal impairment who are at higher risk for in-hospital complications and prolonged length of stay. Results matter to providers and payers because reducing perioperative complications and length of stay can directly impact resource utilization, readmission rates, and the total cost of the episode of care for this high-acuity DRG.
Comparative effectiveness and device-outcome studies at index hospitalization: These trials compare surgical techniques, fixation methods, implant types (including total ankle replacements when appropriate), or intraoperative strategies in patients receiving major hip/knee replacement or reattachment, often stratified by severity and comorbidity burden. The research questions focus on short-term outcomes such as intraoperative blood loss, need for transfusion, immediate postoperative mobility, prosthesis alignment, and early complication rates in the inpatient period. Findings inform surgeon decision-making about approaches that balance clinical benefit and perioperative resource demands, which is critical for DRG-based reimbursement and for hospitals optimizing care pathways for patients with complex medical backgrounds.
Post-discharge outcomes, rehabilitation, and bundle-of-care trials: These studies examine post-acute care pathways, rehabilitation intensity, transitional care models, and readmission-reduction interventions for patients discharged after major joint replacement or limb reattachment—particularly those with multiple chronic conditions who are at risk for functional decline or readmission. Typical endpoints include functional recovery trajectories, 30- to 90-day readmissions, post-acute facility utilization, and patient-reported outcomes, evaluated across different discharge destinations and care coordination models. This research is relevant to providers and payers because improvements in post-discharge management can decrease downstream utilization, improve functional outcomes, and influence total-cost-of-care metrics tied to bundled payments and DRG reimbursement models.

Single Level Combined Anterior and Posterior Spinal Fusion Except Cervical: Inpatient Reimbursement Overview

426-MULTIPLE-LEVEL-COMBINED-ANTERIOR-AND-POSTERIOR-SPINAL-FUSION-EXCEPT-CERVICAL-WITH-MCC-OR-CUSTOM-MADE-ANATOMICALLY-DESIGNED-INTERBODY-FUSION-DEVICE

Multiple Level Combined Anterior and Posterior Spinal Fusion Except Cervical with MCC or Custom-Made Anatomically Designed Interbody Fusion Device: Inpatient Reimbursement Overview

427-MULTIPLE-LEVEL-COMBINED-ANTERIOR-AND-POSTERIOR-SPINAL-FUSION-EXCEPT-CERVICAL-WITH-CC

Multiple Level Combined Anterior and Posterior Spinal Fusion Except Cervical with CC: Inpatient Reimbursement Overview

428-MULTIPLE-LEVEL-COMBINED-ANTERIOR-AND-POSTERIOR-SPINAL-FUSION-EXCEPT-CERVICAL-WITHOUT-CC-MCC

Multiple Level Combined Anterior and Posterior Spinal Fusion Except Cervical without CC/MCC: Inpatient Reimbursement Overview

429-COMBINED-ANTERIOR-AND-POSTERIOR-CERVICAL-SPINAL-FUSION-WITH-MCC

Combined Anterior and Posterior Cervical Spinal Fusion with MCC: Inpatient Reimbursement Overview

430-COMBINED-ANTERIOR-AND-POSTERIOR-CERVICAL-SPINAL-FUSION-WITHOUT-MCC

Combined Anterior and Posterior Cervical Spinal Fusion without MCC: Inpatient Reimbursement Overview

447-MULTIPLE-LEVEL-SPINAL-FUSION-EXCEPT-CERVICAL-WITH-MCC-OR-CUSTOM-MADE-ANATOMICALLY-DESIGNED-INTERBODY-FUSION-DEVICE

Multiple Level Spinal Fusion Except Cervical with MCC: Inpatient Reimbursement Overview

448-MULTIPLE-LEVEL-SPINAL-FUSION-EXCEPT-CERVICAL-WITHOUT-MCC

Multiple Level Spinal Fusion Except Cervical without MCC: Inpatient Reimbursement Overview

450-SINGLE-LEVEL-SPINAL-FUSION-EXCEPT-CERVICAL-WITH-MCC-OR-CUSTOM-MADE-ANATOMICALLY-DESIGNED-INTERBODY-FUSION-DEVICE

Single Level Spinal Fusion Except Cervical with MCC or Custom-Made Device: Inpatient Reimbursement Overview

451-SINGLE-LEVEL-SPINAL-FUSION-EXCEPT-CERVICAL-WITHOUT-MCC

Single Level Spinal Fusion Except Cervical without MCC: Inpatient Reimbursement Overview

Showing 1–10 of 104

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.

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.

Explore openpayer tools

View all tools

National Payment Rates

Mean Rates by Payer — National — DRG 469

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$28K	$140K	$25K	5.7K

Patient Population

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Mean Rates by Payer — Alaska — DRG 469

Key Insights for Alaska

Highest payer: Cigna (median $72K; max $130K) — notably above national medians for multiple payers, indicating a higher ceiling in AK.
Lowest payers: Anthem and BCBS (median $47K; min $7.5K) — both show a wide low-end floor down to $7.5K, which is meaningfully lower than typical national p25 values.
Meaningful deviation: Cigna’s median and max are substantially higher than national medians, while Anthem/BCBS exhibit a much wider range with a very low p25 compared with national benchmarks.

Clinical Trials

Perioperative optimization and complication-prevention trials: These studies evaluate interventions delivered in the immediate preoperative and inpatient periods—such as enhanced prehabilitation protocols, multimodal pain control regimens, thromboprophylaxis strategies, and infection-prevention bundles—for patients undergoing major hip or knee arthroplasty or lower-extremity reattachment with major comorbidities (MCC). The population typically includes older adults with cardiovascular disease, diabetes, obesity, or renal impairment who are at higher risk for in-hospital complications and prolonged length of stay. Results matter to providers and payers because reducing perioperative complications and length of stay can directly impact resource utilization, readmission rates, and the total cost of the episode of care for this high-acuity DRG.
Comparative effectiveness and device-outcome studies at index hospitalization: These trials compare surgical techniques, fixation methods, implant types (including total ankle replacements when appropriate), or intraoperative strategies in patients receiving major hip/knee replacement or reattachment, often stratified by severity and comorbidity burden. The research questions focus on short-term outcomes such as intraoperative blood loss, need for transfusion, immediate postoperative mobility, prosthesis alignment, and early complication rates in the inpatient period. Findings inform surgeon decision-making about approaches that balance clinical benefit and perioperative resource demands, which is critical for DRG-based reimbursement and for hospitals optimizing care pathways for patients with complex medical backgrounds.
Post-discharge outcomes, rehabilitation, and bundle-of-care trials: These studies examine post-acute care pathways, rehabilitation intensity, transitional care models, and readmission-reduction interventions for patients discharged after major joint replacement or limb reattachment—particularly those with multiple chronic conditions who are at risk for functional decline or readmission. Typical endpoints include functional recovery trajectories, 30- to 90-day readmissions, post-acute facility utilization, and patient-reported outcomes, evaluated across different discharge destinations and care coordination models. This research is relevant to providers and payers because improvements in post-discharge management can decrease downstream utilization, improve functional outcomes, and influence total-cost-of-care metrics tied to bundled payments and DRG reimbursement models.

Single Level Combined Anterior and Posterior Spinal Fusion Except Cervical: Inpatient Reimbursement Overview

426-MULTIPLE-LEVEL-COMBINED-ANTERIOR-AND-POSTERIOR-SPINAL-FUSION-EXCEPT-CERVICAL-WITH-MCC-OR-CUSTOM-MADE-ANATOMICALLY-DESIGNED-INTERBODY-FUSION-DEVICE

Multiple Level Combined Anterior and Posterior Spinal Fusion Except Cervical with MCC or Custom-Made Anatomically Designed Interbody Fusion Device: Inpatient Reimbursement Overview

427-MULTIPLE-LEVEL-COMBINED-ANTERIOR-AND-POSTERIOR-SPINAL-FUSION-EXCEPT-CERVICAL-WITH-CC

Multiple Level Combined Anterior and Posterior Spinal Fusion Except Cervical with CC: Inpatient Reimbursement Overview

428-MULTIPLE-LEVEL-COMBINED-ANTERIOR-AND-POSTERIOR-SPINAL-FUSION-EXCEPT-CERVICAL-WITHOUT-CC-MCC

Multiple Level Combined Anterior and Posterior Spinal Fusion Except Cervical without CC/MCC: Inpatient Reimbursement Overview

429-COMBINED-ANTERIOR-AND-POSTERIOR-CERVICAL-SPINAL-FUSION-WITH-MCC

Combined Anterior and Posterior Cervical Spinal Fusion with MCC: Inpatient Reimbursement Overview

430-COMBINED-ANTERIOR-AND-POSTERIOR-CERVICAL-SPINAL-FUSION-WITHOUT-MCC

Combined Anterior and Posterior Cervical Spinal Fusion without MCC: Inpatient Reimbursement Overview

447-MULTIPLE-LEVEL-SPINAL-FUSION-EXCEPT-CERVICAL-WITH-MCC-OR-CUSTOM-MADE-ANATOMICALLY-DESIGNED-INTERBODY-FUSION-DEVICE

Multiple Level Spinal Fusion Except Cervical with MCC: Inpatient Reimbursement Overview

448-MULTIPLE-LEVEL-SPINAL-FUSION-EXCEPT-CERVICAL-WITHOUT-MCC

Multiple Level Spinal Fusion Except Cervical without MCC: Inpatient Reimbursement Overview

450-SINGLE-LEVEL-SPINAL-FUSION-EXCEPT-CERVICAL-WITH-MCC-OR-CUSTOM-MADE-ANATOMICALLY-DESIGNED-INTERBODY-FUSION-DEVICE

Single Level Spinal Fusion Except Cervical with MCC or Custom-Made Device: Inpatient Reimbursement Overview

451-SINGLE-LEVEL-SPINAL-FUSION-EXCEPT-CERVICAL-WITHOUT-MCC

Single Level Spinal Fusion Except Cervical without MCC: Inpatient Reimbursement Overview

Showing 1–10 of 104

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

Major Hip and Knee Joint Replacement or Reattachment: Inpatient Reimbursement Overview

Sign up for drg 469 policy alerts

DRG 469 Overview

OpenPayer

Major Hip and Knee Joint Replacement or Reattachment: Inpatient Reimbursement Overview

Sign up for drg 469 policy alerts

DRG 469 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