Diagnostic Related Groups (DRGs) are primarily used to determine reimbursement for inpatient stays. Every inpatient visit is placed into one DRG category based on the patient’s primary diagnosis, procedures performed, and discharge status.
Each DRG is given a weighted value relative to the time and resources required to effectively administer care for the average patient. This value is multiplied by a preset dollar amount unique to each hospital that reflects its individual status (teaching hospitals have higher reimbursements, for example) and service area demographics (such as average local wage levels) to find the total reimbursement amount.
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|DRG Code||Description||Primary Diagnoses||Secondary Diagnoses||Total Diagnoses||Explore These Claims|
|871||SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 OR MORE HOURS WITH MAJOR COMPLICATIONS OR COMORBIDITIES||1,561,768||30,073,944||31,635,712||Explore This Code|
|291||HEART FAILURE & SHOCK WITH MAJOR COMPLICATIONS OR COMORBIDITIES||856,939||17,434,940||18,291,879||Explore This Code|
|885||PSYCHOSES||1,747,938||10,822,350||12,570,288||Explore This Code|
|470||MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MAJOR COMPLICATIONS OR COMORBIDITIES||1,243,482||10,604,418||11,847,901||Explore This Code|
|189||PULMONARY EDEMA & RESPIRATORY FAILURE||401,116||7,222,032||7,623,148||Explore This Code|
|193||SIMPLE PNEUMONIA & PLEURISY WITH MAJOR COMPLICATIONS OR COMORBIDITIES||521,986||6,902,469||7,424,455||Explore This Code|
|872||SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV 96 OR MORE HOURS WITHOUT MAJOR COMPLICATIONS OR COMORBIDITIES||413,660||6,680,699||7,094,359||Explore This Code|
|683||RENAL FAILURE WITH COMPLICATIONS OR COMORBIDITIES||327,071||5,860,082||6,187,153||Explore This Code|
|190||CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MAJOR COMPLICATIONS OR COMORBIDITIES||334,283||5,748,894||6,083,178||Explore This Code|
|392||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS WITHOUT MAJOR COMPLICATIONS OR COMORBIDITIES||583,558||5,278,962||5,862,520||Explore This Code|
|378||G.I. HEMORRHAGE WITH COMPLICATIONS OR COMORBIDITIES||328,215||5,268,827||5,597,042||Explore This Code|
|682||RENAL FAILURE WITH MAJOR COMPLICATIONS OR COMORBIDITIES||270,431||5,276,632||5,547,063||Explore This Code|
|690||KIDNEY & URINARY TRACT INFECTIONS WITHOUT MAJOR COMPLICATIONS OR COMORBIDITIES||371,892||5,058,390||5,430,282||Explore This Code|
|853||INFECTIOUS & PARASITIC DISEASES WITH O.R. PROCEDURE WITH MAJOR COMPLICATIONS OR COMORBIDITIES||238,447||5,177,641||5,416,088||Explore This Code|
|194||SIMPLE PNEUMONIA & PLEURISY WITH COMPLICATIONS OR COMORBIDITIES||419,662||4,724,175||5,143,837||Explore This Code|
|065||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH COMPLICATIONS OR COMORBIDITIES||291,924||4,114,065||4,405,989||Explore This Code|
|280||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MAJOR COMPLICATIONS OR COMORBIDITIES||230,796||4,092,150||4,322,946||Explore This Code|
|057||DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MAJOR COMPLICATIONS OR COMORBIDITIES||262,000||4,016,285||4,278,286||Explore This Code|
|603||CELLULITIS WITHOUT MAJOR COMPLICATIONS OR COMORBIDITIES||399,944||3,859,873||4,259,817||Explore This Code|
|064||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MAJOR COMPLICATIONS OR COMORBIDITIES||230,407||3,854,119||4,084,526||Explore This Code|
|292||HEART FAILURE & SHOCK WITH COMPLICATIONS OR COMORBIDITIES||232,105||3,842,211||4,074,316||Explore This Code|
|177||RESPIRATORY INFECTIONS & INFLAMMATIONS WITH MAJOR COMPLICATIONS OR COMORBIDITIES||191,153||3,603,734||3,794,887||Explore This Code|
|689||KIDNEY & URINARY TRACT INFECTIONS WITH MAJOR COMPLICATIONS OR COMORBIDITIES||205,740||3,527,787||3,733,527||Explore This Code|
|640||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES WITH MAJOR COMPLICATIONS OR COMORBIDITIES||211,128||3,501,901||3,713,029||Explore This Code|
|641||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES WITHOUT MAJOR COMPLICATIONS OR COMORBIDITIES||257,758||3,403,970||3,661,729||Explore This Code|
Fig. 1 Data from Definitive Healthcare’s Hospitals and IDNs database. Annual Medicare Data is from the Centers for Medicare and Medicaid Services (CMS) Medicare Standard Analytical Files (SAF). Data from calendar year 2018 (most recent complete data set available). Accessed June 2020.
The most common diagnosis by hospital admissions volume is septicemia, followed by heart failure and shock in second, and then psychoses in third. In 2018, diagnoses for septicemia reached an approximate 31.6 million, 30 million of which were secondary diagnoses.
Definitive Healthcare’s claims data shows that total diagnoses of heart failure and shock increased substantially since 2016, where it previously ranked as the fourth highest diagnosis by volume — 11.6 million in 2016 vs. 18.2 million in 2018.
Psychoses saw 12.5 million total diagnoses in 2018, on par with previous years. Part of the reason for the consistently high psychoses volumes is the definition of the DRG itself. Its subcategories include multiple types of severe mental illnesses that can require inpatient treatment, such as schizophrenia, bipolar disorder with manic episodes, and severe depression.