CPT 01630: Anesthesia for Shoulder and Axilla Procedures - OpenPayer

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Summary & Overview

CPT 01630: Anesthesia for Shoulder and Axilla Procedures

CPT code 01630 covers anesthesia services for procedures involving the shoulder and axilla, a critical component in surgical care for these regions. This code is widely used across outpatient hospital settings, reflecting its importance in both routine and complex orthopedic and surgical interventions. The publication provides a comprehensive overview of national billing practices, payer coverage, and clinical context for 01630, focusing on major commercial insurers including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare.

Readers will gain insight into the scope of procedures associated with 01630, typical sites of service, and relevant modifiers used in billing. The summary also highlights associated provider taxonomies and common ICD-10 diagnoses linked to shoulder and axilla procedures, offering a clear understanding of clinical scenarios where this code is applied. Additionally, related CPT codes are discussed to clarify distinctions in anesthesia billing for similar procedures. The publication serves as a resource for understanding policy updates, reimbursement benchmarks, and the evolving landscape of anesthesia services for shoulder and axilla interventions.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareCPT 01630anesthesiashoulder proceduresaxilla proceduresoutpatient hospitalmedical billingclinical codingprovider taxonomyICD-10 diagnosesprocedure benchmarks

CPT Code Overview

CPT code 01630 is designated for anesthesia services provided during procedures on the shoulder and axilla. This code is used to report the administration of anesthesia by qualified professionals for surgical interventions in these anatomical regions. The service type is anesthesia, and the typical site of service is an outpatient hospital (Place of Service 22). This code is essential for accurately documenting and billing anesthesia care associated with shoulder and axilla procedures in outpatient settings.

Clinical & Coding Specifications

Clinical Context

A patient presents to the outpatient hospital with a shoulder or axilla injury or condition requiring surgical intervention. The patient may have a diagnosis such as pain in the right knee, tear of the medial meniscus, or fracture of the upper end of the right tibia, but for this scenario, the focus is on procedures involving the shoulder and axilla. An anesthesiology provider, such as an anesthesiologist, certified registered nurse anesthetist, or anesthesiology assistant, administers anesthesia for the surgical procedure. The clinical workflow includes preoperative assessment, induction and maintenance of anesthesia, intraoperative monitoring, and postoperative care. The anesthesia service is coded with CPT code 01630 for procedures on the shoulder and axilla, typically performed in an outpatient hospital setting (Place of Service 22).

Coding Specifications

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

National Reimbursement Benchmarks

National mean rates for CPT code 01630 show significant variation across commercial payers. Aetna and Cigna report the highest mean rates at $320.08 and $299.28, respectively, while UnitedHealth Group is notably lower at $65.62. The BUCA (average commercial) mean rate stands at $184.50, which is substantially higher than UnitedHealth Group but lower than Aetna and Cigna. Medicare data is not available in the input.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies widely. Aetna exhibits the widest spread ($488.00 - $44.00 = $444.00), indicating substantial variability in contracted rates. Blue Cross Blue Shield has a much tighter range ($316.20 - $204.50 = $111.70), suggesting more consistent reimbursement levels. UnitedHealth Group and BUCA also show relatively narrow dispersions, with $25.18 and $205.33, respectively. Cigna's range is $344.00, reflecting considerable variability.

The table and chart below present a full breakdown of national benchmarks for each payer, including mean rates and percentile values.

State Benchmarks

State: AK1 / 50

Alaska Benchmarks

Alaska exhibits a wide rate spread for CPT code 01630 among commercial payers. Blue Cross Blue Shield shows the largest spread, with a 75th percentile rate of $370.00 and a 25th percentile rate of $274.60, resulting in a $95.40 difference. Aetna and UnitedHealth Group both have a narrow spread, with only $30.00 and $3.00 between their 75th and 25th percentiles, respectively. Cigna's rates are tightly clustered, with just an $8.00 spread. Compared to national averages, Blue Cross Blue Shield and Aetna have higher mean rates in Alaska, while Cigna and UnitedHealth Group are notably lower than their national benchmarks.

The table and chart below present the full breakdown of payer-specific reimbursement rates for CPT code 01630 in Alaska, highlighting the significant variation across payers.

Key Insights for Alaska

Blue Cross Blue Shield is the highest paying payer for CPT 01630 in Alaska, with a mean rate of $327.60.
UnitedHealth Group offers the lowest mean rate at $74.78, significantly below both state and national averages.
Cigna's mean rate in Alaska ($89.33) is much lower than its national mean ($299.28), indicating a substantial deviation.

Related Codes

01320

CPT 01320: Anesthesia for Knee and Popliteal Area Procedures

01272

CPT 01272: Anesthesia for Upper Leg Vascular Procedures (Femoral Artery)

01432

CPT 01432: Anesthesia for Knee and Popliteal Vein Arteriovenous Fistula Procedures

01638

CPT 01638: Anesthesia for Shoulder and Axilla Procedures

01392

CPT 01392: Anesthesia for Knee Area Surgery

01470

CPT 01470: Anesthesia for Lower Leg, Ankle, and Foot Procedures

01430

CPT 01430: Anesthesia for Knee Joint Procedures, Not Otherwise Specified

01210

CPT 01210: Anesthesia for Open Hip Joint Procedures

01486

CPT 01486: Anesthesia for Open Lower Leg, Ankle, and Foot Procedures

01340

CPT 01340: Anesthesia for Closed Procedures on Lower Third of Femur

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