Summary & Overview
Splenic Procedures without CC/MCC: Inpatient Reimbursement Overview
DRG 801 encompasses inpatient admissions involving splenic procedures without a Major Complication or Comorbidity and without a Complication or Comorbidity, defining a lower-severity surgical cohort for Medicare payment. Correct assignment matters because it influences Medicare payment classification, hospital case-mix index contribution, and reimbursement for splenic surgical services.
DRG 801 Overview
DRG 801 covers inpatient hospital cases involving splenic procedures without a Major Complication or Comorbidity and without a Complication or Comorbidity, typically including partial or total splenectomy for conditions that do not generate additional coded complexity. This Diagnosis-Related Group groups clinically similar resource use for Medicare payment, affecting payment assignment, hospital billing, and case-mix indexing. The DRG is relevant for surgical, general surgery, trauma, and hematology services where splenic operations are performed. Accurate coding of accompanying diagnoses and procedures determines whether a case is assigned to this DRG or to a higher-severity category.
National Payment Rates
Across commercial payers the observed rate range spans roughly from $15K to $54K, with Anthem and Aetna showing lower and higher extremes respectively; the widest spread between payer medians appears between Anthem and Aetna. Refer to the table and chart below for payer-specific quartiles and distributions. Payer labels in the visuals use Blue Cross Blue Shield, UnitedHealth Group, Cigna, Aetna, and Anthem for clarity.
The CMS 2023 data represent national Medicare fee-for-service inpatient payments as reported in the CMS Provider Utilization and Payment Data program. The table below shows average total payment ($16.4k), average submitted covered charges ($75.7k), average Medicare payment ($11.5k), and total discharges (68).
| Average Total Payment | Average Submitted Charges | Average Medicare Payment | Total Discharges |
|---|---|---|---|
| $16K | $76K | $11K | 68 |
Patient Population
This DRG’s population is mixed but tends to include a substantial Medicare-age cohort alongside working-age commercially insured patients. The presence of Medicare fee-for-service discharges indicates meaningful utilization by Medicare beneficiaries, while commercial payer benchmarks show active participation from private insurers. Overall, the population skews toward a combined Medicare and working-age mix rather than exclusively one age group.