TYPE CODE CODE DESCRIPTION PRICE (AED) Anaesthesia procedure code

CPT 01770 Anesthesia for procedures on arteries of upper arm and elbow; not otherwise specified 396

CPT 01772 Anesthesia for procedures on arteries of upper arm and elbow; embolectomy 396

CPT 01780 Anesthesia for procedures on veins of upper arm and elbow; not otherwise specified 198

CPT 01782 Anesthesia for procedures on veins of upper arm and elbow; phleborrhaphy 264

CPT 01810 Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand 198

CPT 01820 Anesthesia for all closed procedures on radius, ulna, wrist, or hand bones 198

CPT 01829 Anesthesia for diagnostic arthroscopic procedures on the wrist198

CPT 01830 Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; not otherwise specified 198

CPT 01832 Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; total wrist replacement 396

CPT 01840 Anesthesia for procedures on arteries of forearm, wrist, and hand; not otherwise specified 396

CPT 01842 Anesthesia for procedures on arteries of forearm, wrist, and hand; embolectomy 396

CPT 01844 Anesthesia for vascular shunt, or shunt revision, any type (eg, dialysis) 396

CPT 01850 Anesthesia for procedures on veins of forearm, wrist, and hand; not otherwise specified 198

CPT 01852 Anesthesia for procedures on veins of forearm, wrist, and hand; phleborrhaphy 264

CPT 01860 Anesthesia for forearm, wrist, or hand cast application, removal, or repair 198

CPT 01916 Anesthesia for diagnostic arteriography/venography 330

CPT 01920 Anesthesia for cardiac catheterization including coronary angiography and ventriculography (not to include SwanGanz catheter) 462

CPT 01922 Anesthesia for non-invasive imaging or radiation therapy 462

CPT 01924 Anesthesia for therapeutic interventional radiological procedures involving the arterial system; not otherwise specified 330

CPT 01925 Anesthesia for therapeutic interventional radiological procedures involving the arterial system; carotid or coronary 462

CPT 01926 Anesthesia for therapeutic interventional radiological procedures involving the arterial system; intracranial, intracardiac, or aortic 528

CPT 01930 Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); not otherwise specified 330

CPT 01931 Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intrahepatic or portal circulation (eg, transvenous intrahepatic portosystemic shunt[s] [TIPS]) 462

CPT 01932 Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intrathoracic or jugular 396

CPT 01933 Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intracranial 462

CPT 01935 Anesthesia for percutaneous image guided procedures on the spine and spinal cord; diagnostic 330

CPT 01936 Anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic 330

CPT 01951 Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; less than 4% total body surface area 198

CPT 01952 Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; between 4% and 9% of total body surface area 330

CPT 01953 Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; each additional 9% total body surface area or part thereof (List separately in addition to code for primary procedure) 66

CPT 01958 Anesthesia for external cephalic version procedure 330

CPT 01960 Anesthesia for vaginal delivery only 330

CPT 01961 Anesthesia for cesarean delivery only 462

CPT 01962 Anesthesia for urgent hysterectomy following delivery 528

CPT 01963 Anesthesia for cesarean hysterectomy without any labor analgesia/anesthesia care 528

CPT 01965 Anesthesia for incomplete or missed abortion procedures 264

CPT 01966 Anesthesia for induced abortion procedures 264

CPT 01967 Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor) 330

CPT 01968 Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed) 132

CPT 01969 Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed) 330

CPT 01990 Physiological support for harvesting of organ(s) from braindead patient 462

CPT 01991 Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different provider); other than the prone position 198


CPT 01992 Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different provider); prone position 330

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered.

  • In keeping with the American Society of Anesthesiologists’ standards for monitoring, MAC should be provided by qualified anesthesia personnel in accordance with individual state licensure. These individuals must be continuously present to monitor the patient and provide anesthesia care.
  • During MAC, the patient’s oxygenation, ventilation, circulation and temperature should be evaluated by whatever methods are deemed most suitable by the attending anesthetist. It is anticipated that newer methods of non-invasive monitoring such as pulse oximetry and capnography will be frequently relied upon. Close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive and/or result in unforeseen complications requires comprehensive monitoring and/or anesthetic intervention.
  • The following CMS requirements for this type of anesthesia should be the same as for general anesthesia with regard to:
    • The performance of preanesthetic examination and evaluation.
    • The prescription of the anesthesia care required.
    • The completion of an anesthesia record.
    • The administration of necessary medications and the provision of indicated postoperative anesthesia care.
  • Appropriate documentation must be available to reflect pre- and postanesthetic evaluations and intraoperative monitoring.
  • The MAC service rendered must be reasonable, appropriate and medically necessary.
  • Anesthesia procedures listed in the “CPT/HCPCS Codes” section of this LCD are examples of those that are usually provided by the attending surgeon and are included in the global fee and are not separately billable. In certain instances; however, MAC provided by anesthesia personnel may be necessary for these procedures if the patient has one or more of the conditions or situations found in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD. MAC may be necessary for these active and serious accompanying situations or conditions to ensure smooth anesthesia (and surgery) by the prevention of adverse physiologic complications. The use of anesthesia modifiers, when the CPT code is not fully descriptive, is required as follows:
    • G8 anesthesia modifier – used to indicate certain deep, complex, complicated or markedly invasive surgical procedures. This modifier is to be applied to the following anesthesia codes only: 00100, 00300, 00400, 00160, 00532 and 00920.

    • G9 anesthesia modifier – represents “a history of severe cardiopulmonary disease” and should be utilized whenever the proceduralist feels the need for MAC due to a history of advanced cardiopulmonary disease. The documentation of this clinical decision-making process and the need for additional monitoring must be clearly documented in the medical record.
    • Anesthesia codes utilized to indicate the clinical condition of the patient receiving MAC: P1 healthy individual with minimal anesthesia risk, P2 mild systemic disease, P3 severe systemic disease with intermittent threat of morbidity or mortality, P4 severe systemic illness with ongoing threat of morbidity or mortality, P5 premorbid condition with high risk of demise unless procedural intervention is performed.


Special conditions and/or criteria must be supported by documentation in the medical record.

  • Reimbursement for MAC will be the same amount allowed for full general anesthesia services if all requirements listed under these indications are met. The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic. If the requirements are not fulfilled or the procedures are unnecessary, payment will be denied in full.
  • For procedures that do not usually require anesthesia services, MAC could be covered when the patient’s condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented in the patient’s medical record.
  • The presence of an underlying condition alone, as reported by an ICD-9-CM diagnosis code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient.
  • Conditions listed under the “Diagnoses That Support Medical Necessity” section of this LCD, if matched with anesthesia procedures in the “CPT/HCPCS Codes” section of this LCD, could support the need for MAC. Other disease states can also be considered if medical justification is demonstrated.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.


Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11X, 12X, 13X, 18X, 21X, 83X


Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all the CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
037X
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Procedures listed below usually do not require general, regional or MAC anesthesia.
00100©
Anesth, salivary gland
00124©
Anesth, ear exam
00148©
Anesth, eye exam
00160©
Anesth, nose/sinus surgery
00164©
Anesth, biopsy of nose
00300©
Anesth, head/neck/ptrunk
00322©
Anesth, biopsy of thyroid
00400©
Anesth, skin, ext/per/atrunk
00410©
Anesth, correct heart rhythm
00454©
Anesth, collar bone biopsy
00520©
Anesth, chest procedure
00522©
Anesth, chest lining biopsy
00524©
Anesth, chest drainage
00530©
Anesth, pacemaker insertion
00532©
Anesth, vascular access
00635©
Anesth, lumbar puncture
00640©
Anesth, spine manipulation
00702©
Anesth, for liver biopsy
00740©
Anesth, upper gi visualize
00810©
Anesth, low intestine scope
00842©
Anesth, amniocentesis
00920©
Anesth, genitalia surgery
00921©
Anesth, vasectomy
01130©
Anesth, body cast procedure
01380©
Anesth, knee joint procedure
01420©
Anesth, knee joint casting
01490©
Anesth, lower leg casting
01680©
Anesth, shoulder casting
01682©
Anesth, airplane cast
01730©
Anesth, uppr arm procedure
01780©
Anesth, upper arm vein surg
01782©
Anesth, uppr arm vein repair
01820©
Anesth, lower arm procedure
01829©
Anesth, dx wrist arthroscopy
01860©
Anesth, lower arm casting
01916©
Anesth, dx arteriography
01920©
Anesth, catheterize heart
01922©
Anesth, cat or mri scan
01930©
Anes, ther interven rad, vein
01935©
Anesth, perc img dx sp proc
01936©
Anesth, perc img tx sp proc
01991©
Anesth, nerve block/inj
01992©
Anesth, n block/inj, prone
01999©
Unlisted anesth procedure
Note: The QS modifier must be used with the anesthesia service provided if MAC is delivered.