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Diagnostic Related Groups, or DRGs, are primarily used to determine reimbursement for inpatient stays. Every inpatient visit is placed into one DRG category based upon the patient’s primary diagnosis, procedures performed, and discharge status. Each DRG is given a weighted value above or below one that represents the relative time and resources required to effectively care for the average patient with a specific diagnosis until discharge. 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. The average of a hospital’s DRG weights over a given period determines its case mix.

The most common primary diagnosis for hospital admissions by far is septicemia, followed by psychoses. In 2016, primary diagnoses for septicemia reached an estimated 1.3 million, and secondary diagnoses were approximately 24.5 million. Primary diagnoses for psychoses reached 1.9 million in 2016, and secondary diagnoses totaled more than 10.4 million. Part of the reason for the high psychoses volumes is the definition of the DRG itself, as its subcategories include multiple types of severe mental ailments that can require inpatient treatment, such as schizophrenia, bipolar disorder with manic episodes, and severe depression. Major joint replacement of the lower extremity (knee) without complications or co-morbidity was the third most common primary diagnosis, followed by heart failure & shock and pulmonary edema & respiratory failure.

Each of the top 10, with the exception of psychoses, also have related DRGs that specify additional characteristics for the patient group, such as the presence of major complications or comorbidities. For most of them, diagnoses involving complications or comorbidities were more common than those without. One important exception is knee replacement surgery, which is usually performed on an elective basis. Another is esophagitis and other gastrointestinal disorders.

Top 25 Diagnostic Related Groups by Volume

  DRG Description DRG Number Total Diagnoses Primary Diagnoses Secondary Diagnoses

1.

SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 OR MORE HOURS W MCC

871

25,880,228

1,323,063

24,557,164

2.

PSYCHOSES

885

12,367,662

1,946,391

10,421,270

3.

MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOW­ER EXTREMITY W/O MCC

470

12,069,147

1,328,567

10,740,580

4.

HEART FAILURE & SHOCK W MCC

291

11,628,950

547,609

11,081,341

5.

PULMONARY EDEMA & RESPIRATORY FAILURE

189

7,019,374

379,198

6,640,176

6.

HEART FAILURE & SHOCK W CC

292

6,900,102

366,282

6,533,820

7.

ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC

392

6,282,378

621,104

5,661,275

8.

SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 OR MORE HOURS W/O MCC

872

6,281,622

378,074

5,903,548

9.

RENAL FAILURE W CC

683

6,072,120

337,733

5,734,387

10.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC

190

6,042,098

337,578

5,704,520

11.

RENAL FAILURE W MCC

682

5,672,627

293,196

5,379,431

12.

SIMPLE PNEUMONIA & PLEURISY W MCC

193

5,663,996

353,813

5,310,183

13.

KIDNEY & URINARY TRACT INFECTIONS W/O MCC

690

5,446,537

386,371

5,060,165

14.

G.I. HEMORRHAGE W CC

378

5,086,448

301,690

4,784,758

15.

INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC

853

4,925,089

221,461

4,703,628

16.

SIMPLE PNEUMONIA & PLEURISY W CC

194

4,729,581

338,703

4,390,879

17.

CELLULITIS W/O MCC

603

4,417,268

427,079

3,990,190

18.

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC

065

4,287,020

294,019

3,993,001

19.

DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC

057

4,022,199

251,905

3,770,295

20.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC

191

3,741,101

218,327

3,522,773

21.

MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC

641

3,627,604

261,884

3,365,720

22.

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC

064

3,456,677

206,000

3,250,677

23.

CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC

309

3,423,915

216,078

3,207,836

24.

KIDNEY & URINARY TRACT INFECTIONS W MCC

689

3,333,233

188,755

3,144,478

25.

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC

280

3,315,057

188,489

3,126,568

Fig 1. Data from Definitive Healthcare based on Annual Medicare Data from the 2016 Medicare SAF (1/1/2016 - 12/31/2016). Complete Calendar Year 2017 data is projected to be released in fall 2018 by the Centers for Medicare and Medicaid Services (CMS). All-Payer estimates are based on Definitive Healthcare calculations and algorithms.

Common Conditions by Associated DRG Diagnoses

  Condition Associated DRGs Total Diagnoses

1.

Septicemia / Sepsis

870, 871, 872

34,052,323

2.

Heart Failure & Shock

291, 292, 293

20,172,471

3.

Knee Replacement

469, 470

13,147,543

4.

Renal Failure

682, 683, 684

12,498,893

5.

Psychoses

885

12,367,662

6.

Intracranial Hemorrhage or Cerebral Infarction

64, 65, 66

8,919,082

7.

Respiratory Failure & Pneumonia

189, 193, 194, 195

8,654,578

8.

Esophagitis & Misc Digestive Disorders

391, 392

8,223,429

9.

Heart Attack

280, 281, 282, 283, 284, 285

4,573,170

10.

Rehabilitation

945, 946

634,387

Fig 2. Data from Definitive Healthcare based on Annual Medicare Data from the 2016 Medicare SAF (1/1/2016 - 12/31/2016). Complete Calendar Year 2017 data is projected to be released in fall 2018 by the Centers for Medicare and Medicaid Services (CMS). All-Payor estimates are based on Definitive Healthcare calculations and algorithms.