Hip and Femur Procedures Except Major Joint with CC DRG Reimbursement

DRG 481 includes hip and femur procedures except major joint replacement when a Complication or Comorbidity is present, covering operations such as fracture fixation and related surgical management. It matters for inpatient reimbursement because the Complication or Comorbidity designation increases the Diagnosis-Related Group payment to account for higher resource needs during the hospital stay.

DRG 481 Overview

DRG 481 covers inpatient hospitalizations for hip and femur procedures except major joint replacement when a Complication or Comorbidity is present. Typical cases include open or closed treatment of hip fractures, femoral shaft fractures, and similar operative procedures where additional diagnoses increase resource use. This Diagnosis-Related Group matters for Medicare payment because the presence of a Complication or Comorbidity adjusts reimbursement to reflect higher expected costs and length of stay. Payers and hospitals use the DRG assignment to determine prospective payment for the inpatient episode.

DRG 481 Overview

Across commercial payers, negotiated rates for DRG 481 range from about $370 to $73K, with mean payer-specific averages spanning roughly $19K to $35K and payer medians from $18K to $37K; the widest spread observed is between the minimum $370 and the maximum $73K. See the table and chart below for payer-level distributions and percentile detail. Payer labels in the benchmark table correspond to Blue Cross Blue Shield, Cigna, Anthem, and Aetna.

The CMS 2023 data reflect national Medicare fee-for-service inpatient payments 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 481. These values summarize national Medicare payment experience for this DRG in 2023.

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$18K	$94K	$15K	67K

Patient Population

This DRG’s patients skew toward Medicare-age beneficiaries, reflecting a predominantly older population rather than primarily working-age. Commercial payers (Blue Cross Blue Shield, Cigna, Aetna, Anthem) cover a smaller share relative to Medicare, indicating a mixed but Medicare-leaning payer mix. The distribution implies more cases originate from the Medicare fee-for-service population than from employer-sponsored commercial plans.

Alaska Benchmarks

Alaska payer means for DRG 481 range from $33K (Anthem and Blue Cross Blue Shield) up to $50K (Cigna), with Cigna also showing the widest observed max of $84K. This state distribution skews higher than several national medians, driven largely by Cigna’s elevated mean and max values. See the table and chart below for payer-level detail.

Key Insights for Alaska

Highest payer: Cigna at $50K mean (range up to $84K); Lowest payer: Blue Cross Blue Shield/Anthem at $33K mean.
Alaska’s payer means center around $33K–$50K, with Cigna notably above national means for Cigna and other national payers, while Blue Cross Blue Shield and Anthem sit below national medians.

Acute perioperative optimization trials focusing on blood management and hemodynamic protocols for patients undergoing hip and femur procedures with complicating comorbidities. These studies enroll older adults with hip fractures or proximal femur surgeries who have cardiovascular disease, anemia, or other CCs to evaluate strategies such as restrictive versus liberal transfusion thresholds, goal‑directed fluid therapy, and multimodal analgesia to reduce immediate postoperative complications. Results inform inpatient clinical pathways that can shorten length of stay and reduce costly complications, which is directly relevant to hospital reimbursement and DRG cost containment.
Comparative effectiveness studies evaluating surgical approach, fixation methods, or implant selection for femoral fracture repair in medically complex patients. These trials compare outcomes such as reoperation, infection, functional recovery, and in‑hospital resource use between techniques (for example intramedullary nailing versus plate fixation) or between different fixation philosophies in frail older adults with multiple chronic conditions. Evidence helps surgeons and payers determine which procedures yield the best balance of effectiveness and resource utilization within the DRG, guiding case selection and coverage policies.
Post-discharge outcomes and transitional care interventions assessing readmission reduction, rehabilitation models, and long‑term functional recovery after hip and femur procedures in patients with significant comorbidity. These pragmatic trials or cohort studies examine discharge timing, home versus skilled nursing rehabilitation, and coordinated case management for patients at high risk of readmission or prolonged institutional care. Findings are important for payers and providers aiming to optimize bundled payment performance and reduce downstream costs associated with readmissions and long-term care placement.

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$18K	$94K	$15K	67K

Patient Population

Alaska Benchmarks

Key Insights for Alaska

Highest payer: Cigna at $50K mean (range up to $84K); Lowest payer: Blue Cross Blue Shield/Anthem at $33K mean.
Alaska’s payer means center around $33K–$50K, with Cigna notably above national means for Cigna and other national payers, while Blue Cross Blue Shield and Anthem sit below national medians.

Acute perioperative optimization trials focusing on blood management and hemodynamic protocols for patients undergoing hip and femur procedures with complicating comorbidities. These studies enroll older adults with hip fractures or proximal femur surgeries who have cardiovascular disease, anemia, or other CCs to evaluate strategies such as restrictive versus liberal transfusion thresholds, goal‑directed fluid therapy, and multimodal analgesia to reduce immediate postoperative complications. Results inform inpatient clinical pathways that can shorten length of stay and reduce costly complications, which is directly relevant to hospital reimbursement and DRG cost containment.
Comparative effectiveness studies evaluating surgical approach, fixation methods, or implant selection for femoral fracture repair in medically complex patients. These trials compare outcomes such as reoperation, infection, functional recovery, and in‑hospital resource use between techniques (for example intramedullary nailing versus plate fixation) or between different fixation philosophies in frail older adults with multiple chronic conditions. Evidence helps surgeons and payers determine which procedures yield the best balance of effectiveness and resource utilization within the DRG, guiding case selection and coverage policies.
Post-discharge outcomes and transitional care interventions assessing readmission reduction, rehabilitation models, and long‑term functional recovery after hip and femur procedures in patients with significant comorbidity. These pragmatic trials or cohort studies examine discharge timing, home versus skilled nursing rehabilitation, and coordinated case management for patients at high risk of readmission or prolonged institutional care. Findings are important for payers and providers aiming to optimize bundled payment performance and reduce downstream costs associated with readmissions and long-term care placement.

OpenPayer

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

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DRG 481 Overview

OpenPayer

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

Sign up for drg 481 policy alerts

DRG 481 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