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    OpenPayerBilling CodesInjuries, Poisonings and Toxic Effects of DrugsDRG 916-allergic-reactions-without-mcc
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    Allergic Reactions without MCC: Inpatient Reimbursement Overview

    DRG 916 addresses inpatient admissions for allergic reactions that do not include a Major Complication or Comorbidity, covering conditions like urticaria, angioedema, and non-severe anaphylaxis. Accurate DRG assignment matters for inpatient reimbursement because it establishes the Medicare payment level tied to expected resource use for lower-severity allergic reaction care.

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    DRG 916 Overview

    DRG 916 covers inpatient admissions for allergic reactions without a Major Complication or Comorbidity and typically includes conditions such as urticaria, angioedema, mild to moderate anaphylactic reactions, and other hypersensitivity presentations that do not meet severity thresholds for higher-weighted groups. This Diagnosis-Related Group is used to classify cases where the primary management is stabilization, observation, and treatment without significant organ dysfunction or intensive interventions. It matters for Medicare payment because assignment to this group determines base reimbursement for hospitals when no Major Complication or Comorbidity is present, affecting resource allocation and billing for routine inpatient care of allergic reactions. Reimbursement under this Diagnosis-Related Group reflects average expected resource use for these lower-severity allergic reaction admissions.

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    National Payment Rates

    Across commercial payers the reported mean rates for DRG 916 range from $6.1K (BCBS) to $11K (Cigna/Aetna), with observed payer medians spanning roughly $5.7K to $12K; the widest spread between payer minimums and maximums in the table is about $22.6K (Anthem min ~$390 to max $23K). See the table and chart below for payer-specific distributions and percentile details. These benchmarks allow comparison of private payer performance versus the CMS Medicare results.

    The CMS 2023 data represent national Medicare fee‑for‑service inpatient payments published under the CMS Provider Utilization and Payment Data program. The table below shows average total payment, average submitted covered charges, average Medicare payment amount, and total discharges for DRG 916. Values reflect Medicare payments and utilization at the national level for 2023.

    Average Total PaymentAverage Submitted ChargesAverage Medicare PaymentTotal Discharges
    $6.8K$30K$4.7K2.1K

    Patient Population

    This DRG’s inpatient population includes both Medicare‑age and working‑age adults, reflecting a mixed payer composition rather than being confined to Medicare‑only patients. Commercial payers (Cigna, Aetna, BCBS, Anthem) represent a substantial portion of non‑Medicare admissions, while Medicare covers a meaningful share given age‑related utilization. Overall, the population skews mixed between working‑age and Medicare‑age beneficiaries.

    State Payment Rates

    State: Alaska1 / 49

    Alaska Benchmarks

    Alaska’s payer means for DRG 916 range from 11K (Anthem and Blue Cross Blue Shield) up to 17K (Cigna), reflecting a fairly wide spread across payers. The most notable deviation versus national context is Cigna’s mean of 17K, which sits above typical national means presented. See the table and chart below for the payer-level distribution and percentiles.

    Key Insights for Alaska

    • Highest payer: Cigna with a mean of 17K; lowest payer: Anthem and Blue Cross Blue Shield (BCBS) both with a mean of 11K.
    • Alaska’s mean rates skew higher than some national means for this DRG, with Cigna at 17K notably above the national payer means shown; Anthem/BCBS at 11K align with or slightly above certain national averages.

    Clinical Trials

    • Acute emergency management trials evaluating rapid diagnostic algorithms and immediate therapeutic strategies for hospitalized patients presenting with moderate-to-severe allergic reactions (excluding those with major complications). These studies enroll adults and children admitted for suspected anaphylaxis, urticaria with systemic symptoms, or severe allergic contact reactions, testing protocols that streamline use of epinephrine, antihistamines, corticosteroids, and observation pathways in the ED and inpatient setting. Results are relevant to providers and payers because optimized acute pathways can reduce unnecessary admissions, shorten length of stay, and improve resource utilization while ensuring patient safety.
    • Comparative effectiveness studies comparing in-hospital management approaches and care pathways for non‑MCC allergic reactions, such as early discharge with outpatient follow-up versus short-stay observation or standard inpatient admission. These investigations focus on populations with comorbid allergic disease but without major complications, assessing outcomes like symptom recurrence, readmission rates, patient-reported recovery, and cost per episode of care. Findings inform clinicians and payers about which care settings and treatment bundles deliver equivalent clinical outcomes at lower cost and support evidence-based utilization management and payment decisions.
    • Post-discharge outcomes and secondary prevention research assessing follow-up interventions to reduce recurrence and improve long-term control after an inpatient episode for allergic reaction. Studies in this area enroll patients discharged after an allergic reaction to evaluate structured education, allergy specialist referral, diagnostic testing uptake, and adherence to avoidance strategies or maintenance medications, measuring downstream healthcare utilization, subsequent ED visits, and quality-of-life metrics. This research is pertinent to payers and providers because effective post-discharge programs can lower future acute care use and total cost of care by preventing recurrent admissions and improving chronic management of allergic conditions.

    Related Codes

    901-WOUND-DEBRIDEMENTS-FOR-INJURIES-WITH-MCC

    Wound Debridements for Injuries with MCC: Inpatient Reimbursement Overview

    902-WOUND-DEBRIDEMENTS-FOR-INJURIES-WITH-CC

    Wound Debridements for Injuries with CC: Inpatient Reimbursement Overview

    903-WOUND-DEBRIDEMENTS-FOR-INJURIES-WITHOUT-CC-MCC

    Wound Debridements for Injuries without CC/MCC: Inpatient Reimbursement Overview

    904-SKIN-GRAFTS-FOR-INJURIES-WITH-CC-MCC

    Skin Grafts for Injuries with CC/MCC: Inpatient Reimbursement Overview

    905-SKIN-GRAFTS-FOR-INJURIES-WITHOUT-CC-MCC

    Skin Grafts for Injuries without CC/MCC: Inpatient Reimbursement Overview

    906-HAND-PROCEDURES-FOR-INJURIES

    Hand Procedures for Injuries: Inpatient Reimbursement Overview

    907-OTHER-O-R-PROCEDURES-FOR-INJURIES-WITH-MCC

    Other O.R. Procedures for Injuries with MCC: Inpatient Reimbursement Overview

    908-OTHER-O-R-PROCEDURES-FOR-INJURIES-WITH-CC

    Other O.R. Procedures for Injuries with CC: Inpatient Reimbursement Overview

    909-OTHER-O-R-PROCEDURES-FOR-INJURIES-WITHOUT-CC-MCC

    Other O.R. Procedures for Injuries without CC/MCC: Inpatient Reimbursement Overview

    913-TRAUMATIC-INJURY-WITH-MCC

    Traumatic Injury with MCC: Inpatient Reimbursement Overview

    Showing 1–10 of 19

    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.
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    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.

    Mean Rates by Payer — National — DRG 916
    Mean Rates by Payer — Alaska — DRG 916