Summary & Overview
Simple Pneumonia and Pleurisy with MCC: Inpatient Reimbursement Overview
DRG 193 encompasses admissions for simple pneumonia and pleurisy complicated by a Major Complication or Comorbidity, capturing cases with markedly higher resource needs. It matters for inpatient reimbursement because the presence of an MCC increases the Medicare Severity Diagnosis-Related Group relative weight and payment, aligning reimbursement with expected hospital resource use.
DRG 193 Overview
Diagnosis-Related Group 193 covers hospital admissions for simple pneumonia and pleurisy when a Major Complication or Comorbidity (MCC) is present. Typical patients have pneumonia or pleural inflammation with additional severe comorbid conditions that significantly increase resource use, such as respiratory failure or severe sepsis. This grouping affects Medicare payments by assigning higher relative weights and payment rates compared with cases without MCC, reflecting greater expected hospitalization costs. Accurate coding of the MCC status is therefore critical for correct inpatient reimbursement under Medicare Severity Diagnosis-Related Group (MS-DRG) rules.
National Payment Rates
Mean payer rates range from $9,428.93 for Medicare up to $22,064.13 for Aetna, with a spread of $12,635.20 between the lowest and highest means; the widest interquartile spread appears among Anthem and Aetna payers. See the table and chart below for payer-level means and percentile markers. Blue Cross Blue Shield, Cigna, Aetna, and Anthem are shown by name, and BUCA reflects the precomputed composite.
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