Hip and Femur Procedures Except Major Joint DRG Reimbursement

DRG 480 encompasses hip and femur procedures except major joint replacement when a Major Complication or Comorbidity is present, covering complex fracture repairs and similar high-acuity surgical admissions. Correct assignment matters for inpatient reimbursement because the Major Complication or Comorbidity designation increases relative resource use and influences Medicare payment.

DRG 480 Overview

DRG 480 covers inpatient admissions for hip and femur procedures except major joint replacement when a Major Complication or Comorbidity is present, typically including complex fracture repairs, periprosthetic fracture management, and other nonarthroplasty femoral or hip surgeries with significant comorbidity burden. This Diagnosis-Related Group matters for Medicare payment because the presence of a Major Complication or Comorbidity increases relative resource use and reimbursement relative to similar procedures without such complications. Hospitals and coders must accurately capture diagnosis and procedure coding to align the clinical record with billing classification. Payment under this group reflects expected higher inpatient resource intensity due to the severity of illness and complexity of care.

DRG 480 Overview

Across payers the reported rate range runs from as low as $370 (BCBS minimum) up to $110K (Anthem maximum), with mean payer benchmarks spanning roughly $27K to $47K. The widest spread appears between Anthem (max $110K) and BCBS (min $370), indicating substantial variability across the market. See the table and chart below for payer-specific percentiles and distributions.

The CMS 2023 data represent 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 480. These values summarize payer activity for Medicare FFS at the national level.

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$25K	$130K	$23K	29K

Patient Population

DRG 480’s hospitalized population skews toward older, Medicare-age patients rather than exclusively working-age adults, reflecting a payer mix with a substantial Medicare share. Commercial/private payers (e.g., Aetna, Anthem, Cigna, BCBS) are present but the population is primarily Medicare-aged with a smaller working-age representation. This results in a mixed but Medicare-leaning payer composition nationally.

Alaska Benchmarks

Alaska exhibits a wide rate range across payers for DRG 480, from $45K (Blue Cross Blue Shield and Anthem) up to $120K (Cigna). The most notable deviation from national averages is Cigna’s $120K level, which is substantially higher than typical national medians. See the table and chart below for payer-level detail.

Key Insights for Alaska

Highest payer: Cigna at $120K; Lowest payers: Blue Cross Blue Shield and Anthem at $45K each.
Cigna in Alaska ($120K) sits well above typical national medians and represents a meaningful high-side outlier versus national payer medians.
The statewide payer range is wide ($45K–$120K), indicating substantial variation across payers within Alaska.

Acute surgical optimization and perioperative complication reduction trials: These studies evaluate interventions during the hospital stay—such as blood management protocols, enhanced anesthesia strategies, or infection prevention bundles—for patients undergoing hip and femur procedures with major complications or comorbidities. The population includes older adults with hip fractures or complex femur surgeries who have multiple comorbid conditions and are at high risk for perioperative morbidity and prolonged length of stay. Results inform providers and payers about approaches that reduce in-hospital complications, ICU utilization, transfusions, and unplanned readmissions, directly impacting DRG resource use and costs.
Comparative effectiveness studies of surgical techniques and fixation strategies: Trials comparing different operative approaches (for example, intramedullary nailing versus plate fixation, or different prosthesis types when applicable) or timing of surgery for femur and hip procedures examine functional outcomes, reoperation rates, and short-term mortality. The patient cohorts are typically older adults or trauma patients with femoral shaft fractures or non–major joint hip procedures, often stratified by frailty and osteoporosis. These studies are relevant because they identify which surgical choices lead to shorter hospital stays, fewer complications, and better early recovery—key drivers of inpatient reimbursement and DRG classification decisions.
Post-discharge recovery and care transition studies focused on rehabilitation, discharge disposition, and readmission prevention: Research in this area tests models of post-acute care such as early mobility programs, tailored home health interventions, or coordinated transitional care for patients discharged after hip and femur surgeries, including those with significant comorbidities. Populations studied include patients discharged to home, skilled nursing facilities, or inpatient rehab who are at risk for functional decline or readmission within 30 days. Findings help payers and hospital systems optimize discharge planning, lower costly readmissions, and align post-acute placement with expected outcomes under the DRG payment model.

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$25K	$130K	$23K	29K

Patient Population

Alaska Benchmarks

Key Insights for Alaska

Highest payer: Cigna at $120K; Lowest payers: Blue Cross Blue Shield and Anthem at $45K each.
Cigna in Alaska ($120K) sits well above typical national medians and represents a meaningful high-side outlier versus national payer medians.
The statewide payer range is wide ($45K–$120K), indicating substantial variation across payers within Alaska.

Acute surgical optimization and perioperative complication reduction trials: These studies evaluate interventions during the hospital stay—such as blood management protocols, enhanced anesthesia strategies, or infection prevention bundles—for patients undergoing hip and femur procedures with major complications or comorbidities. The population includes older adults with hip fractures or complex femur surgeries who have multiple comorbid conditions and are at high risk for perioperative morbidity and prolonged length of stay. Results inform providers and payers about approaches that reduce in-hospital complications, ICU utilization, transfusions, and unplanned readmissions, directly impacting DRG resource use and costs.
Comparative effectiveness studies of surgical techniques and fixation strategies: Trials comparing different operative approaches (for example, intramedullary nailing versus plate fixation, or different prosthesis types when applicable) or timing of surgery for femur and hip procedures examine functional outcomes, reoperation rates, and short-term mortality. The patient cohorts are typically older adults or trauma patients with femoral shaft fractures or non–major joint hip procedures, often stratified by frailty and osteoporosis. These studies are relevant because they identify which surgical choices lead to shorter hospital stays, fewer complications, and better early recovery—key drivers of inpatient reimbursement and DRG classification decisions.
Post-discharge recovery and care transition studies focused on rehabilitation, discharge disposition, and readmission prevention: Research in this area tests models of post-acute care such as early mobility programs, tailored home health interventions, or coordinated transitional care for patients discharged after hip and femur surgeries, including those with significant comorbidities. Populations studied include patients discharged to home, skilled nursing facilities, or inpatient rehab who are at risk for functional decline or readmission within 30 days. Findings help payers and hospital systems optimize discharge planning, lower costly readmissions, and align post-acute placement with expected outcomes under the DRG payment model.

OpenPayer

Hip and Femur Procedures Except Major Joint with MCC: Inpatient Reimbursement Overview

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DRG 480 Overview

OpenPayer

Hip and Femur Procedures Except Major Joint with MCC: Inpatient Reimbursement Overview

Sign up for drg 480 policy alerts

DRG 480 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