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 Blood, Blood Forming Organs and Immunologic DisordersDRG 816-reticuloendothelial-and-immunity-disorders-without-cc-mcc
    Ask Trek AI about this page

    Reticuloendothelial and Immunity Disorders without CC/MCC: Inpatient Reimbursement Overview

    DRG 816 encompasses uncomplicated reticuloendothelial and immunity disorders treated in the inpatient setting and is used to classify cases without Complication or Comorbidity or Major Complication or Comorbidity. Accurate assignment matters for inpatient reimbursement because it influences payment rates under the Medicare inpatient prospective payment methodology and hospital case-mix.

    Customize your policy alerts

    Sign up for drg 816 policy alerts

    Get alerted when payer policies referencing 816 are released or updated.

    Monitor payer policy activity

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

    DRG 816 Overview

    DRG 816 covers inpatient cases for reticuloendothelial and immunity disorders without Complication or Comorbidity or Major Complication or Comorbidity, including conditions such as uncomplicated immune deficiencies, certain benign hematologic disorders, and related noncomplicated inflammatory processes. It matters for Medicare payment because assignment to this Diagnosis-Related Group typically reflects lower resource use and lower reimbursement relative to cases with complications or comorbidities, impacting hospital revenue and case-mix reporting. Third-party payers and hospitals use this grouping to classify clinical severity and allocate facility payments under the inpatient prospective payment system. Understanding the clinical scope supports accurate coding and claims submission for Medicare beneficiaries.

    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 immunomodulatory intervention trials testing short-term therapies (for example, corticosteroid-sparing biologic approaches or novel immunosuppressive regimens) in hospitalized patients presenting with severe autoimmune or inflammatory reticuloendothelial disorders. These studies enroll patients admitted for active disease flares or complications (eg, severe cytopenias, systemic inflammation, or organ involvement) and measure rapid clinical response, safety, and time to clinical stabilization. Results are directly relevant to inpatient providers deciding on escalation of care and to payers because they can affect length of stay, use of intensive monitoring, and utilization of high-cost therapies.
    • Comparative effectiveness studies evaluating inpatient management strategies and care pathways for immune-related complications (for example, protocolized transfusion and infection prophylaxis strategies, or head-to-head comparisons of standard immunosuppression protocols). These trials often include heterogeneous hospitalized cohorts with conditions such as autoimmune cytopenias, hemophagocytic syndromes, and other reticuloendothelial disorders to assess outcomes like complication rates, readmissions, and resource utilization. Findings inform best-practice guidelines for clinicians and support payers in determining which inpatient approaches yield better outcomes and lower overall costs.
    • Post-discharge outcomes and transitional care trials focusing on prevention of readmission and long-term disease control after an inpatient episode (for example, structured outpatient follow-up programs, medication adherence interventions, or remote monitoring for early relapse detection). These studies enroll patients discharged after acute management of immunity-related disorders and track rehospitalization rates, outpatient resource use, and patient-reported outcomes over months. This research is important for healthcare systems and payers aiming to reduce costly readmissions and improve chronic disease management through targeted outpatient investments.

    Related Codes

    799-SPLENIC-PROCEDURES-WITH-MCC

    Splenic Procedures with MCC: Inpatient Reimbursement Overview

    800-SPLENIC-PROCEDURES-WITH-CC

    Splenic Procedures with CC: Inpatient Reimbursement Overview

    801-SPLENIC-PROCEDURES-WITHOUT-CC-MCC

    Splenic Procedures without CC/MCC: Inpatient Reimbursement Overview

    802-OTHER-O-R-PROCEDURES-OF-THE-BLOOD-AND-BLOOD-FORMING-ORGANS-WITH-MCC

    Other O.R. Procedures of the Blood and Blood Forming Organs with MCC: Inpatient Reimbursement Overview

    803-OTHER-O-R-PROCEDURES-OF-THE-BLOOD-AND-BLOOD-FORMING-ORGANS-WITH-CC

    Other O.R. Procedures of the Blood and Blood Forming Organs with CC: Inpatient Reimbursement Overview

    804-OTHER-O-R-PROCEDURES-OF-THE-BLOOD-AND-BLOOD-FORMING-ORGANS-WITHOUT-CC-MCC

    Other O.R. Procedures of the Blood and Blood Forming Organs without CC/MCC: Inpatient Reimbursement Overview

    808-MAJOR-HEMATOLOGICAL-AND-IMMUNOLOGICAL-DIAGNOSES-EXCEPT-SICKLE-CELL-CRISIS-AND-COAGULATION-DISORDERS-WITH-MCC

    Major Hematological and Immunological Diagnoses: Inpatient Reimbursement Overview

    809-MAJOR-HEMATOLOGICAL-AND-IMMUNOLOGICAL-DIAGNOSES-EXCEPT-SICKLE-CELL-CRISIS-AND-COAGULATION-DISORDERS-WITH-CC

    Major Hematological and Immunological Diagnoses: Inpatient Reimbursement Overview

    810-MAJOR-HEMATOLOGICAL-AND-IMMUNOLOGICAL-DIAGNOSES-EXCEPT-SICKLE-CELL-CRISIS-AND-COAGULATION-DISORDERS-WITHOUT-CC-MCC

    Major Hematological and Immunological Diagnoses: Inpatient Reimbursement Overview

    811-RED-BLOOD-CELL-DISORDERS-WITH-MCC

    Red Blood Cell Disorders with MCC: Inpatient Reimbursement Overview

    Showing 1–10 of 14

    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.