Diabetes with Complication or Comorbidity: Inpatient Reimbursement Overview

DRG 638 addresses inpatient admissions for diabetes with an accompanying Complication or Comorbidity and excludes Major Complication or Comorbidity. This classification matters for inpatient reimbursement because it groups patients by expected resource use to determine Medicare payment under the prospective payment system.

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DRG 638 Overview

DRG 638 covers hospital admissions primarily for diabetes mellitus when a Complication or Comorbidity is present but no Major Complication or Comorbidity is coded. It includes a range of diabetic presentations such as hyperglycemia, hypoglycemia, or poorly controlled diabetes requiring inpatient management alongside another coded comorbid condition. This Diagnosis-Related Group affects Medicare payment by grouping clinically similar resource-use cases to set prospective reimbursement for the inpatient stay. Proper coding of associated conditions determines case assignment and impacts payment.

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Diabetes with Complication or Comorbidity: Inpatient Reimbursement Overview

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Sign up for drg 638 policy alerts

Get alerted when payer policies referencing 638 are released or updated.

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DRG 638 Overview

National Payment Rates

Across commercial payers the observed rate range spans roughly $370 to $31K, with payer medians clustered between $8K and $16K. The widest spread appears between BCBS (min $370, max $23K) and Anthem (min $390, max $31K). See the table and chart below for payer-specific quartiles and distribution details.

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 ($8.6k), average submitted covered charges ($39.5k), average Medicare payment amount ($6.5k), and total discharges (32.7k).

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$8.6K	$39K	$6.5K	33K

Patient Population

This DRG’s patient population skews toward Medicare-age beneficiaries, reflecting a predominance of older adults rather than primarily working-age patients. Commercial payers (Aetna, Anthem, Cigna, BCBS) still account for a portion of admissions, indicating a mixed but Medicare-leaning payer mix. The presence of substantial Medicare discharges in the CMS data aligns with a population that is largely Medicare-eligible.

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Across payers in Alaska for DRG 638, observed payment means range from about $15K (Anthem and Blue Cross Blue Shield) up to $22K (Cigna), with payer-specific maxima from $23K to $38K and minima near $7.5K. The most notable deviation versus national averages is Cigna’s substantially higher upper-end (max $38K) compared with national maxima, while Anthem/Blue Cross Blue Shield sit below national medians. See the table and chart below for the full distribution by payer.

Key Insights for Alaska

Highest-paying payer: Cigna (state max $38K, mean $22K); Lowest-paying payer: Anthem/BCBS (state mean $15K, min $7.5K).
Alaska’s payer range spans approximately $7.5K to $38K, with Cigna markedly above national means for several percentiles and Anthem/BCBS clustered below national medians.

Clinical Trials

Trials evaluating inpatient glycemic management protocols that compare different insulin delivery strategies (e.g., basal-bolus protocols, scheduled correctional insulin algorithms, and standardized sliding scale discontinuation pathways) in adults hospitalized with diabetes complicated by acute comorbidities. These studies enroll patients with hyperglycemia and one or more CCs such as infection, heart failure exacerbation, or renal impairment to assess glycemic control, hypoglycemia rates, length of stay, and short-term complications. Findings are directly relevant to hospitalists and payers because optimized inpatient glycemic protocols can reduce hypoglycemia-related adverse events, shorten admissions, and influence resource utilization and reimbursement under bundled or DRG-based payment models.
Comparative effectiveness studies of inpatient care bundles that target common diabetes-related complications (for example, combined infection management plus glycemic control versus usual care) in patients admitted with diabetes and a complication such as diabetic foot infection or sepsis secondary to soft-tissue infection. These pragmatic trials include heterogeneous adults with CCs, examine outcomes like readmission, wound healing, need for surgery, and total cost of care over 30–90 days, and often incorporate subgroup analyses by renal function or cardiovascular comorbidity. Results inform clinicians and payers about which multidisciplinary, protocolized approaches yield better clinical outcomes and lower downstream expenditures for this high-risk DRG cohort.
Post-discharge transitional care and secondary prevention studies testing discharge interventions (structured diabetes education, medication reconciliation with simplified insulin regimens, remote glucose monitoring, or early outpatient follow-up) in patients hospitalized for diabetes with CC who are at high risk for readmission. These randomized or quasi-experimental studies focus on the transition from inpatient to ambulatory care, enrolling patients with comorbid conditions like chronic kidney disease or heart failure to measure 30–180 day readmission rates, emergency visits, glycemic control, and total cost of care. For providers and payers, evidence from these studies identifies scalable strategies to reduce readmissions, improve outpatient disease control, and lower penalties or costs associated with recurrent admissions under DRG-based payment systems.

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References

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.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.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.

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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.

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National Payment Rates

Mean Rates by Payer — National — DRG 638

Average Total Payment	Average Submitted Charges	Average Medicare Payment	Total Discharges
$8.6K	$39K	$6.5K	33K

Patient Population

State Payment Rates

State: Alaska1 / 49

Alaska Benchmarks

Mean Rates by Payer — Alaska — DRG 638

Key Insights for Alaska

Highest-paying payer: Cigna (state max $38K, mean $22K); Lowest-paying payer: Anthem/BCBS (state mean $15K, min $7.5K).
Alaska’s payer range spans approximately $7.5K to $38K, with Cigna markedly above national means for several percentiles and Anthem/BCBS clustered below national medians.

Clinical Trials

Trials evaluating inpatient glycemic management protocols that compare different insulin delivery strategies (e.g., basal-bolus protocols, scheduled correctional insulin algorithms, and standardized sliding scale discontinuation pathways) in adults hospitalized with diabetes complicated by acute comorbidities. These studies enroll patients with hyperglycemia and one or more CCs such as infection, heart failure exacerbation, or renal impairment to assess glycemic control, hypoglycemia rates, length of stay, and short-term complications. Findings are directly relevant to hospitalists and payers because optimized inpatient glycemic protocols can reduce hypoglycemia-related adverse events, shorten admissions, and influence resource utilization and reimbursement under bundled or DRG-based payment models.
Comparative effectiveness studies of inpatient care bundles that target common diabetes-related complications (for example, combined infection management plus glycemic control versus usual care) in patients admitted with diabetes and a complication such as diabetic foot infection or sepsis secondary to soft-tissue infection. These pragmatic trials include heterogeneous adults with CCs, examine outcomes like readmission, wound healing, need for surgery, and total cost of care over 30–90 days, and often incorporate subgroup analyses by renal function or cardiovascular comorbidity. Results inform clinicians and payers about which multidisciplinary, protocolized approaches yield better clinical outcomes and lower downstream expenditures for this high-risk DRG cohort.
Post-discharge transitional care and secondary prevention studies testing discharge interventions (structured diabetes education, medication reconciliation with simplified insulin regimens, remote glucose monitoring, or early outpatient follow-up) in patients hospitalized for diabetes with CC who are at high risk for readmission. These randomized or quasi-experimental studies focus on the transition from inpatient to ambulatory care, enrolling patients with comorbid conditions like chronic kidney disease or heart failure to measure 30–180 day readmission rates, emergency visits, glycemic control, and total cost of care. For providers and payers, evidence from these studies identifies scalable strategies to reduce readmissions, improve outpatient disease control, and lower penalties or costs associated with recurrent admissions under DRG-based payment systems.

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Showing 1–10 of 25

References

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.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.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.

OpenPayer

Diabetes with Complication or Comorbidity: Inpatient Reimbursement Overview

Sign up for drg 638 policy alerts

DRG 638 Overview

OpenPayer

Diabetes with Complication or Comorbidity: Inpatient Reimbursement Overview

Sign up for drg 638 policy alerts

DRG 638 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