Summary & Overview
Simple Pneumonia and Pleurisy without CC/MCC: Inpatient Reimbursement Overview
Diagnosis-Related Group 195 designates inpatient stays for simple pneumonia and pleurisy without Complication or Comorbidity or Major Complication or Comorbidity and encompasses less complex respiratory infections appropriate for standard inpatient management. It matters for inpatient reimbursement because assignment to 195 yields lower average Medicare payment relative to pneumonia DRGs with CCs or MCCs and influences hospital revenue, resource allocation, and case-mix index.
DRG 195 Overview
Diagnosis-Related Group 195, Simple Pneumonia and Pleurisy without Major Complication or Comorbidity (MCC) or Complication or Comorbidity (CC), covers hospital inpatient stays for routine community-acquired or uncomplicated pneumonia and pleural inflammation that do not meet criteria for higher-severity DRGs. This DRG groups cases with relatively lower resource use compared with pneumonia with CC/MCC, impacting average payment and length-of-stay expectations under Medicare inpatient Prospective Payment System. Accurate clinical coding and documentation determine assignment to 195, which in turn affects reimbursement and hospital case-mix classification. The category is commonly encountered in general medicine, hospitalist, and pulmonary services.
National Payment Rates
Mean payer rates range from $4,215.22 for Medicare up to $11,458.36 for Aetna, with a wide overall spread of $7,243.14 across payers. Commercial plans such as Aetna, Cigna, and Anthem sit near the top of the range while Blue Cross Blue Shield and BUCA are in the midrange. See the table and chart below for the full payer breakdown.
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.