Major Hip and Knee Joint Replacement DRG Reimbursement

Summary & Overview

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.

Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCCDRG Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCCDRG 470Diagnosis-Related GroupInpatient ReimbursementMedicareOrthopedicsArthroplastyJoint ReplacementLower Extremity Surgery

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.

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.

Mean Rates by Payer — National — DRG 470

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

540-OSTEOMYELITIS-WITH-CC

Osteomyelitis with Complication or Comorbidity: Inpatient Reimbursement Overview

473-CERVICAL-SPINAL-FUSION-WITHOUT-CC-MCC

Cervical Spinal Fusion without CC/MCC: Inpatient Reimbursement Overview

557-TENDONITIS-MYOSITIS-AND-BURSITIS-WITH-MCC

Tendonitis, Myositis and Bursitis with MCC: Inpatient Reimbursement Overview

519-BACK-AND-NECK-PROCEDURES-EXCEPT-SPINAL-FUSION-WITH-CC

Back and Neck Procedures Except Spinal Fusion with CC: Inpatient Reimbursement Overview

536-FRACTURES-OF-HIP-AND-PELVIS-WITHOUT-MCC

Fractures of Hip and Pelvis without MCC: Inpatient Reimbursement Overview

477-BIOPSIES-OF-MUSCULOSKELETAL-SYSTEM-AND-CONNECTIVE-TISSUE-WITH-MCC

Biopsies of Musculoskeletal System and Connective Tissue with MCC: Inpatient Reimbursement Overview

561-AFTERCARE-MUSCULOSKELETAL-SYSTEM-AND-CONNECTIVE-TISSUE-WITHOUT-CC-MCC

Aftercare, Musculoskeletal System and Connective Tissue without CC/MCC: Inpatient Reimbursement Overview

553-BONE-DISEASES-AND-ARTHROPATHIES-WITH-MCC

Bone Diseases and Arthropathies with MCC: Inpatient Reimbursement Overview

513-HAND-OR-WRIST-PROCEDURES-EXCEPT-MAJOR-THUMB-OR-JOINT-PROCEDURES-WITH-CC-MCC

Hand or Wrist Procedures, Except Major Thumb or Joint Procedures with CC/MCC: Inpatient Reimbursement Overview

489-KNEE-PROCEDURES-WITHOUT-PRINCIPAL-DIAGNOSIS-OF-INFECTION-WITHOUT-CC-MCC

Knee Procedures without Principal Diagnosis of Infection without CC/MCC: Inpatient Reimbursement Overview

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OpenPayer

Summary & Overview

Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC: Inpatient Reimbursement Overview

DRG 470 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