CPT 00454 Reimbursement Benchmarks | OpenPayer

Summary & Overview

CPT 00454: Anesthesia for Clavicle and Scapula Procedures

CPT code 00454 covers anesthesia services for procedures involving the clavicle and scapula, a critical component in orthopedic and trauma surgeries. This code is nationally recognized and utilized in outpatient hospital settings, reflecting its importance in ensuring patient safety and comfort during complex upper body operations. The publication provides a comprehensive overview of CPT code 00454, including its clinical context, typical site of service, and relevance to anesthesia professionals.

Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, highlighting the broad coverage and policy considerations across major commercial insurers. Readers will gain insights into current benchmarks, policy updates, and the clinical landscape surrounding anesthesia for clavicle and scapula procedures. The summary also addresses common modifiers, associated taxonomies, and related diagnoses, offering a well-rounded perspective for stakeholders in medical billing, compliance, and clinical operations.

This article is designed for healthcare administrators, billing professionals, and clinical teams seeking clarity on CPT code 00454, its application, and payer coverage. The information presented supports informed decision-making and enhances understanding of anesthesia billing practices for upper extremity procedures.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareCPT 00454anesthesiaclaviclescapulaoutpatient hospitalmedical billingorthopedic surgeryprocedure codingclinical contextpolicy updates

CPT Code Overview

CPT code 00454 is designated for anesthesia services provided during procedures on the clavicle and scapula. This code is used to report the administration of anesthesia for surgical interventions involving these bones, ensuring patient comfort and safety throughout the procedure. The typical site of service for CPT code 00454 is an outpatient hospital setting, classified as Place of Service (POS) 22. This code is integral to the delivery of anesthesia care in orthopedic and trauma cases involving the shoulder girdle.

Clinical & Coding Specifications

Clinical Context

A patient presents to an outpatient hospital (Place of Service 22) for a surgical procedure involving the clavicle or scapula, such as repair of a fracture or removal of a lesion. The anesthesia team, which may include an anesthesiologist, anesthesiology assistant, or certified registered nurse anesthetist (CRNA), provides anesthesia services to ensure the patient is safely sedated and pain-free during the procedure. The clinical workflow involves preoperative assessment, administration of anesthesia, intraoperative monitoring, and postoperative recovery. The anesthesia service is coded with CPT code 00454 for procedures on the clavicle and scapula.

Coding Specifications

Modifiers:
- QS: Monitored anesthesia care service. Used when the anesthesia provider delivers monitored anesthesia care (MAC) rather than general anesthesia.
- QX: CRNA service with medical direction by a physician. Used when a certified registered nurse anesthetist (CRNA) provides anesthesia under the medical direction of a physician.
Provider Taxonomies:

Taxonomy Code

National Reimbursement Benchmarks

National mean rates for CPT code 00454 show that Blue Cross Blue Shield and Cigna reimburse at the highest levels, with mean rates of $210.57 and $198.48, respectively. UnitedHealth Group is the lowest among the major commercial payers, with a mean rate of $65.58. The BUCA average commercial benchmark stands at $107.81, which is notably higher than UnitedHealth Group but well below Blue Cross Blue Shield and Cigna.

Rate dispersion varies significantly across payers. Blue Cross Blue Shield and Cigna exhibit the widest ranges between the 75th and 25th percentiles ($139.00 and $172.33, respectively), indicating substantial variability in contracted rates. In contrast, UnitedHealth Group has the tightest range at $25.50, suggesting more consistent reimbursement levels. Aetna and BUCA also show considerable dispersion, with ranges of $166.00 and $104.00, respectively.

The table and chart below present a detailed breakdown of national benchmarks for CPT code 00454 by payer, including mean rates and percentile values.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska demonstrates a wide range in reimbursement rates for CPT code 00454, with Blue Cross Blue Shield offering the highest mean rate at $221.17 and UnitedHealth Group the lowest at $75.12. The rate spread, calculated as the difference between the 75th and 25th percentiles, is most pronounced for Blue Cross Blue Shield ($87.33), indicating significant variability in payments within this payer. Other payers, such as Aetna, Cigna, and UnitedHealth Group, show much narrower spreads, with their 25th and 75th percentiles nearly identical, suggesting more consistent rates.

When compared to national averages, Blue Cross Blue Shield in Alaska pays notably more, while Aetna and Cigna reimburse at lower rates than their national benchmarks. The table and chart below present the full breakdown of payer-specific rates for Alaska, highlighting these differences and the overall distribution of payments for CPT code 00454.

Key Insights for Alaska

Blue Cross Blue Shield offers the highest mean reimbursement rate for CPT 00454 in Alaska at $221.17, while UnitedHealth Group is the lowest at $75.12.
The rate spread in Alaska is substantial, with BCBS's 75th percentile ($269.00) far exceeding the lowest 25th percentiles among payers.
Compared to national averages, Aetna and Cigna pay less in Alaska, while Blue Cross Blue Shield pays notably more.

CPT 00402: Anesthesia for Neck, Esophagus, and Airway Procedures

00400-ANESTHESIA-FOR-PROCEDURES-ON-THE-INTEGUMENTARY-SYSTEM-ON

CPT 00400: Anesthesia for Skin and Soft Tissue Procedures on Extremities and Trunk

00450-ANESTHESIA-FOR-PROCEDURES-ON-CLAVICLE-AND

CPT 00450: Anesthesia for Clavicle and Scapula Procedures

00404-ANESTHESIA-FOR-PROCEDURES-ON-THE-INTEGUMENTARY-SYSTEM-ON

CPT 00404: Anesthesia for Radical Breast and Integumentary Procedures

00472-ANESTHESIA-FOR-PARTIAL-RIB

CPT 00472: Anesthesia for Partial Rib Resection

00470-ANESTHESIA-FOR-PARTIAL-RIB

CPT 00470: Anesthesia for Partial Rib Resection

00410-ANESTHESIA-FOR-PROCEDURE-TO-CORRECT-ABNORMAL-HEART

CPT 00410: Anesthesia for Procedure to Correct Abnormal Heart Rhythm

00474-ANESTHESIA-FOR-PROCEDURES-ON-THE-THORAX-CHEST-WALL-AND

CPT 00474: Anesthesia for Thoracic Procedures, Chest Wall and Shoulder Girdle

00406-ANESTH-SURGERY-OF

CPT 00406: Anesthesia for Breast Surgery

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Related CPT Codes

CPT Code	Description	Clinical Relationship
`66984`	Extracapsular cataract removal with insertion of intraocular lens	Not directly related; represents a surgical procedure on the eye, typically requiring anesthesia services.
`66982`	Complex cataract surgery with insertion of intraocular lens	Not directly related; represents a more complex eye surgery, also requiring anesthesia.
`00142`	Anesthesia for procedures on eye muscles	Related as an anesthesia code, but for eye muscle procedures rather than clavicle/scapula.
`00144`	Anesthesia for corneal transplant	Related as an anesthesia code, but for corneal transplant procedures.

Codes 00142 and 00144 are anesthesia codes for other anatomical regions (eye), while 66984 and 66982 are surgical codes for cataract procedures. These codes may be used in similar workflows involving anesthesia, but are not typically used together with 00454 unless multiple procedures are performed.