Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerBilling CodesDiseases and Disorders of the Musculoskeletal System and Connective TissueDRG 538-sprains-strains-and-dislocations-of-hip-pelvis-and-thigh-without-cc-mcc
    Ask Trek AI about this page

    Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh: Inpatient Reimbursement Overview

    DRG 538 addresses inpatient admissions for sprains, strains, and dislocations of the hip, pelvis, and thigh without Complication or Comorbidity or Major Complication or Comorbidity, representing lower-acuity musculoskeletal injuries. Proper Diagnosis-Related Group assignment matters for inpatient reimbursement because it determines the Medicare fixed-payment grouping and reflects expected resource use for these straightforward cases.

    Customize your policy alerts

    Sign up for drg 538 policy alerts

    Get alerted when payer policies referencing 538 are released or updated.

    Monitor payer policy activity

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

    DRG 538 Overview

    DRG 538 covers inpatient stays for sprains, strains, and dislocations of the hip, pelvis, and thigh without Complication or Comorbidity or Major Complication or Comorbidity. This Diagnosis-Related Group captures cases that are generally less complex and resource-intensive than those with complicating conditions. It matters for Medicare payment because the Diagnosis-Related Group assignment determines the fixed inpatient reimbursement amount, influencing hospital payment for routine surgical and nonoperative management of these musculoskeletal injuries. Accurate coding and documentation of the absence of Complication or Comorbidity and Major Complication or Comorbidity are essential to assign DRG 538 correctly.

    Table of contents

    Progress1 / 3

    Explore openpayer tools

    • Billing CodesCPT, HCPCS, DRG & more
    • Reimbursement RatesCommercial vs. Medicare rate reports
    • ProvidersHospitals & facilities
    • PayersPlans & market footprint
    • Taxonomy CodesNUCC specialty codes
    • ModifiersCPT modifiers & usage
    • Prior AuthorizationPA policies by payer & drug
    • Timely FilingFiling deadlines by payer
    • Coverage CriteriaMedical necessity by payer
    • Payer ContactsClaims, PA & appeals contacts
    View all tools

    Clinical Trials

    • Acute management trials evaluating emergency and perioperative interventions for high-grade hip, pelvis, or thigh dislocations and severe sprains/strains: these studies focus on immediate treatment strategies such as timing and techniques of closed or open reduction, anesthesia approaches, and acute stabilization protocols in adult patients presenting to the ED or admitted for observation. They assess short-term outcomes like pain control, neurovascular status, complication rates (e.g., avascular necrosis risk after hip dislocation), and length of stay. Results inform inpatient clinical pathways and resource needs that directly affect hospital costs and utilization for this DRG.
    • Comparative effectiveness studies of different inpatient rehabilitation and early mobilization strategies following reduction or surgical repair: randomized or pragmatic trials compare protocols such as standardized inpatient physical therapy intensity, weight-bearing restrictions, and multimodal pain management versus usual care in older adults and working-age patients with hip/pelvis/thigh injuries. These investigations target functional recovery, readmission rates, discharge disposition (home vs skilled nursing), and time to return to baseline mobility — outcomes that influence both clinical decision-making and payer-covered post-acute resource allocation.
    • Post-discharge outcomes and health services research evaluating long-term functional outcomes, complications, and costs for patients treated for hip/pelvis/thigh sprains, strains, or dislocations without major comorbidities: observational cohort studies and registry analyses follow patients after hospital discharge to measure persistent pain, re-injury rates, need for subsequent procedures, and downstream healthcare utilization. This research identifies predictors of poor recovery and high-cost trajectories, helping providers optimize risk stratification during the index admission and payers design coverage policies and care management programs for this relatively lower-acuity DRG.

    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

    Showing 1–10 of 104

    • More pages

    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.
    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.