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:

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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