Top DRG codes by diagnosis volume
Diagnostic Related Groups (DRGs) are used to categorize patients and reflect Medicare fees and reimbursement for hospital stays. Patients are placed into a DRG category based on their primary diagnosis, procedures performed and discharge status. DRGs ensure that Medicare reimbursements reflect a hospital’s case-mix complexity, or the types and severity of patients they most often treat.
The Definitive Healthcare HospitalView product tracks Medicare inpatient procedures for more than 5,200 U.S. hospitals. DRGs are provided through the Medicare Standard Analytic Files (SAF). Complete calendar year data is typically released each fall for the preceding year. Below, we list the DRGs by the highest total diagnoses volume in 2020.
Top 25 DRGs by total diagnoses
| Rank | DRG Code | Description | Principal diagnoses | Secondary diagnoses | Total diagnoses |
|---|---|---|---|---|---|
| 1 | 871 | SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 OR MORE HOURS W MCC | 1,483,304 | 30,971,319 | 32,454,623 |
| 2 | 177 | RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC | 2,515,176 | 17,333,296 | 19,848,472 |
| 3 | 291 | HEART FAILURE & SHOCK W MCC | 771,981 | 16,840,995 | 17,612,977 |
| 4 | 885 | PSYCHOSES | 1,234,826 | 8,441,611 | 9,676,437 |
| 5 | 872 | SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 OR MORE HOURS W/O MCC | 306,323 | 5,503,156 | 5,809,479 |
| 6 | 853 | INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC | 228,236 | 5,215,208 | 5,443,444 |
| 7 | 189 | PULMONARY EDEMA & RESPIRATORY FAILURE | 258,431 | 4,939,967 | 5,198,398 |
| 8 | 682 | RENAL FAILURE W MCC | 221,278 | 4,672,339 | 4,893,617 |
| 9 | 378 | G.I. HEMORRHAGE W CC | 260,232 | 4,600,628 | 4,860,860 |
| 10 | 193 | SIMPLE PNEUMONIA & PLEURISY W MCC | 278,582 | 4,478,966 | 4,757,548 |
| 11 | 280 | ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC | 229,310 | 4,415,759 | 4,645,070 |
| 12 | 683 | RENAL FAILURE W CC | 224,697 | 4,398,347 | 4,623,044 |
| 13 | 392 | ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC | 418,883 | 4,163,027 | 4,581,910 |
| 14 | 690 | KIDNEY & URINARY TRACT INFECTIONS W/O MCC | 273,338 | 4,099,683 | 4,373,021 |
| 15 | 065 | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC | 326,179 | 3,938,304 | 4,264,483 |
| 16 | 640 | MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC | 218,892 | 3,963,491 | 4,182,383 |
| 17 | 064 | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC | 245,669 | 3,861,914 | 4,107,583 |
| 18 | 470 | MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC | 387,393 | 3,630,550 | 4,017,943 |
| 19 | 698 | OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC | 157,201 | 3,674,770 | 3,831,971 |
| 20 | 057 | DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC | 227,906 | 3,579,281 | 3,807,187 |
| 21 | 377 | G.I. HEMORRHAGE W MCC | 171,796 | 3,484,905 | 3,656,702 |
| 22 | 689 | KIDNEY & URINARY TRACT INFECTIONS W MCC | 185,834 | 3,468,231 | 3,654,065 |
| 23 | 641 | MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC | 216,375 | 3,200,123 | 3,416,498 |
| 24 | 190 | CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC | 166,905 | 3,070,113 | 3,237,018 |
| 25 | 309 | CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC | 228,231 | 2,898,939 | 3,127,171 |
Fig. 1 Data from Definitive Healthcare HospitalView product and sourced from the Medicare Standard Analytic Files (SAF). Data accurate as of June 2022.
What are the most common DRGs?
The most common DRG by total diagnoses is septicemia, or sepsis, at more than 32.4 million diagnoses. Respiratory infections and inflammations had nearly 20 million total diagnoses among Medicare beneficiaries in 2020, likely related to the COVID-19 pandemic. Compared to 2018 data, DRG code 177 Respiratory infections and inflammations was listed as 22nd out of 25 top DRGs and in 2020 it is second. This group also has the highest primary diagnoses on the list at 2.5 million.
How is a DRG calculated?
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.
DRG assignment is based on:
- Principal diagnosis
- Secondary diagnoses
- Patient age and sex
- Discharge status
- Comorbidities and complications
What is an MS-DRG?
The Medicare Severity DRG (MS-DRG) system further differentiates each patient’s severity of illness and associated care costs. The original DRG case-mix system was limited to one or two levels of severity while most MS-DRGs have three levels of severity. This allows hospitals to assess a patient’s needs more accurately without fear of hampering reimbursement.
MS-DRG severity categories include:
- Major Complication / Comorbidity (MMC)
- Complication / Comorbidity (CC)
- Non-Complication / Comorbidity (Non-CC)
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