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 542-pathological-fractures-and-musculoskeletal-and-connective-tissue-malignancy-with-mcc
    Ask Trek AI about this page

    Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy with MCC: Inpatient Reimbursement Overview

    DRG 542 encompasses pathological fractures and musculoskeletal and connective tissue malignancy with Major Complication or Comorbidity, covering inpatient stays requiring surgical, oncologic, or complex supportive care. It matters for inpatient reimbursement because the Major Complication or Comorbidity designation raises resource use and affects Diagnosis-Related Group payment assignment under Medicare.

    Customize your policy alerts

    Sign up for drg 542 policy alerts

    Get alerted when payer policies referencing 542 are released or updated.

    Monitor payer policy activity

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

    DRG 542 Overview

    DRG 542 covers inpatient stays for patients with pathological fractures and musculoskeletal and connective tissue malignancy when a Major Complication or Comorbidity is present. Typical cases include metastatic bone disease, primary bone malignancies, and related pathological fractures requiring inpatient surgical, oncologic, or supportive care. This Diagnosis-Related Group is important for Medicare payment because the presence of a Major Complication or Comorbidity increases resource intensity and influences the inpatient reimbursement weight. Accurate clinical coding of malignancy and Major Complication or Comorbidity status determines payment classification under Medicare rules.

    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 surgical and interventional management trials: studies comparing timing, indications, and techniques for surgical stabilization or palliative orthopedic procedures in patients who present with pathological fractures from primary bone tumors or metastatic musculoskeletal malignancies. These trials typically enroll hospitalized adults with active musculoskeletal or connective tissue cancers complicated by an acute fracture or impending fracture, and they evaluate outcomes such as perioperative complications, need for reoperation, blood loss, and in-hospital mortality. Results inform surgeons, hospitalists, and payers about risk–benefit tradeoffs, resource utilization, and care pathways that influence DRG-level costs and length of stay.
    • Comparative effectiveness and systemic therapy sequencing studies in patients with musculoskeletal and connective tissue malignancies with high complication burden: trials or pragmatic studies assess different systemic therapy approaches (including timing of chemotherapy, targeted or immunomodulatory agents, or radiotherapy) and their impact on local tumor control, fracture risk reduction, and need for inpatient interventions. These studies enroll patients with primary sarcomas or bone metastases who are at high risk for or already have pathological fractures, and they measure outcomes such as progression-free control of skeletal disease, rates of subsequent hospitalization for orthopedic complications, and functional status. Findings are relevant to payers and providers because effective systemic sequencing can reduce inpatient admissions, lower complication-driven costs under the DRG, and improve allocation of bundled care resources.
    • Post-discharge outcomes, rehabilitation, and readmission prevention studies: observational cohorts and randomized trials evaluate inpatient-to-home transitions, rehabilitation intensity, outpatient fracture clinic follow-up models, and supportive care interventions (pain management, bone-strengthening agents, and palliative services) for patients discharged after treatment of pathological fractures or musculoskeletal malignancy-related procedures. These studies focus on older adults and patients with substantial comorbidity who are at high risk for readmission, poor mobility, or need for skilled nursing; endpoints include 30- and 90-day readmission rates, functional recovery, and total cost of care. Evidence from these studies helps hospitals and payers design discharge planning, post-acute care networks, and quality metrics that affect DRG payment adequacy and overall patient outcomes.

    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.