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    v1.0.30
    OpenPayerBilling CodesDiseases and Disorders of the Musculoskeletal System and Connective TissueDRG 470-major-hip-and-knee-joint-replacement-or-reattachment-of-lower-extremity-without-mcc
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    Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC: Inpatient Reimbursement Overview

    DRG 470 addresses major hip and knee joint replacement or reattachment of a lower extremity without Major Complication or Comorbidity; it covers primary elective arthroplasty and comparable procedures. This Diagnosis-Related Group matters for inpatient reimbursement because it defines the payment bundle used by Medicare for common orthopedic surgical admissions and guides hospital billing and resource allocation.

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    DRG 470 Overview

    DRG 470 covers inpatient hospital admissions for major hip and knee joint replacement or reattachment of a lower extremity without a Major Complication or Comorbidity. It includes primary elective total hip and total knee arthroplasty and similar procedures when there is no higher-severity comorbid condition present. This DRG is important because it groups common orthopedic procedures into a bundled payment category that influences Medicare hospital reimbursement and resource planning. Accurate coding and documentation determine assignment to this Diagnosis-Related Group and thereby affect payment levels.

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    National Payment Rates

    Across commercial payers the observed rate range spans roughly from $370 to $73K, with median/typical values clustering between the high-teens and low-thirties across payers. The widest payer spread appears between Anthem (max $73K) and BCBS (max $52K), and variability by payer is visible in the table and chart below. Refer to the table and chart for payer-specific percentiles and distributions.

    The CMS 2023 data represent national Medicare fee-for-service inpatient payments from the CMS Provider Utilization and Payment Data program. The table below shows four columns: average total payment (avg_tot_pymt_amt), average submitted covered charges (avg_submtd_cvrd_chrg), average Medicare payment (avg_mdcr_pymt_amt), and total discharges (tot_dschrgs). These values reflect national-level payment and discharge averages reported for 2023.

    Average Total PaymentAverage Submitted ChargesAverage Medicare PaymentTotal Discharges
    $17K$86K$14K77K

    Patient Population

    This DRG’s patient population skews toward Medicare-age beneficiaries but includes a meaningful share of working-age, commercially insured patients, making it a mixed-age population. Payers therefore include a substantial Medicare fee-for-service component alongside private/commercial coverage. Age distribution leans older than typical working-age-only conditions but is not exclusive to Medicare beneficiaries.

    State Payment Rates

    State: Alaska1 / 49

    Alaska Benchmarks

    In Alaska, DRG 470 payments vary considerably by payer, ranging roughly from $7.5K at the low end (Anthem and Blue Cross Blue Shield) up to $82K maximum observed for Cigna, with means around $28K for Anthem/BCBS and $49K for Cigna. The most notable deviation from national averages is Cigna’s substantially higher mean and upper quartile, producing a wider spread versus national benchmarks. See the table and chart below for payer-level distributions and percentiles.

    Key Insights for Alaska

    • Highest payer: Cigna (median $46K) is the highest-paying payer in Alaska; Lowest payers: Anthem and BCBS (both median $30K) are the lowest among listed payers.
    • Alaska’s payer range spans from about $7.5K–$46K for Anthem/BCBS up to $22K–$82K for Cigna, with Cigna’s mean ($49K) and upper quartile notably above national medians.
    • The state shows a meaningful deviation from national patterns because Cigna’s upper-end and mean payments in Alaska exceed typical national medians, creating wider dispersion than the national benchmarks.

    Clinical Trials

    • Perioperative blood management and anemia optimization studies that evaluate strategies such as preoperative iron supplementation, erythropoiesis-stimulating approaches, and intraoperative blood-conservation protocols in patients scheduled for primary total hip or knee arthroplasty without major complications. These studies typically enroll elective arthroplasty patients with varying baseline hemoglobin and comorbidity profiles to determine effects on transfusion rates, perioperative morbidity, and length of stay. Results are directly relevant to providers and payers because reducing transfusions and anemia-related complications can shorten hospitalization, lower acute care costs, and improve resource utilization for DRG 470 admissions.
    • Comparative effectiveness trials of implant selection and surgical technique (for example cemented versus cementless fixation, or different approaches to knee alignment) in otherwise uncomplicated primary hip or knee replacements, focusing on short- to mid-term functional recovery and readmission rates. These trials recruit generally healthy elective arthroplasty patients without major complications to compare outcomes such as postoperative pain control, early mobility, discharge disposition (home versus facility), and early revision or complication rates. Findings inform surgeons, hospitals, and payers about which device or technique pathways are associated with faster recovery, fewer acute-care complications, and lower overall episode costs within the DRG 470 population.
    • Post-discharge care and rehabilitation pathway studies that assess timing and intensity of physical therapy, home-based versus outpatient rehab, and transitional care models for patients after uncomplicated major hip or knee replacement. These pragmatic or observational studies include patients discharged home or to short-term rehab to evaluate metrics like 30-day readmissions, functional status at 6–12 weeks, patient-reported outcomes, and total post-acute care spending. Understanding optimal post-discharge strategies is crucial for providers and payers to reduce readmissions, optimize recovery trajectories, and manage post-acute expenditures associated with DRG 470 hospitalizations.

    Related Codes

    402-SINGLE-LEVEL-COMBINED-ANTERIOR-AND-POSTERIOR-SPINAL-FUSION-EXCEPT-CERVICAL

    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

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    References

    1. 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. 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. 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 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.

    Mean Rates by Payer — National — DRG 470
    Mean Rates by Payer — Alaska — DRG 470