Summary & Overview
CPT 00542: Anesthesia for Removal of Lung Lining
CPT code 00542 covers anesthesia services for the removal of the lung lining, a critical component of intrathoracic surgical procedures. This code is nationally recognized for its role in ensuring proper billing and documentation of anesthesia care during complex thoracic operations. The procedure is most commonly performed in hospital inpatient settings, reflecting its clinical complexity and the need for specialized anesthesiology expertise.
Major payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare. Understanding coverage and reimbursement policies for CPT code 00542 is vital for hospitals, anesthesiology groups, and billing professionals seeking to navigate payer requirements and optimize compliance.
Readers will gain insight into the clinical context of anesthesia for lung lining removal, relevant benchmarks, and recent policy updates affecting this code. The publication also highlights associated modifiers, taxonomies, and related CPT codes, providing a comprehensive overview for stakeholders involved in anesthesia billing and compliance. This summary serves as a resource for understanding national trends and payer coverage for CPT code 00542.
CPT Code Overview
CPT code 00542 is designated for anesthesia services provided during the removal of the lung lining, a procedure typically performed as part of intrathoracic surgical interventions. This code is used to report anesthesia care for patients undergoing complex thoracic operations, specifically targeting the pleura or other lung linings. The service type is Anesthesia – Intrathoracic Procedures, and the typical site of service is a hospital inpatient setting, such as an operating room. This code is essential for accurately documenting and billing anesthesia services associated with these specialized thoracic surgeries.
Clinical & Coding Specifications
Clinical Context
A patient is admitted to the hospital for surgical removal of the lung lining, typically due to conditions such as congenital heart defects or pulmonary complications. The procedure is performed in an inpatient operating room setting. An anesthesiologist or pediatric anesthesiologist provides anesthesia care throughout the intrathoracic procedure, ensuring patient safety and comfort. The clinical workflow involves preoperative assessment, administration of anesthesia, intraoperative monitoring, and postoperative recovery. This scenario is common in pediatric patients with complex cardiac or pulmonary diagnoses requiring surgical intervention.
Coding Specifications
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Modifiers:
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Modifier
QS: Indicates that monitored anesthesia care service was provided during the procedure. -
Modifier
P1: Used when the patient is a normal healthy individual undergoing anesthesia.
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Provider Taxonomies:
Taxonomy Code Specialty Name 207L00000XAnesthesiology 207LA0401XPediatric Anesthesiology 2080P0203XPediatric Critical Care Medicine
These taxonomies represent providers specializing in anesthesia and critical care, particularly for pediatric patients.
Related Diagnoses
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Q20.0– Common arterial trunk: Relevant for patients with congenital heart defects requiring surgical intervention, which may necessitate removal of lung lining. -
Q21.0– Ventricular septal defect: Often associated with increased pulmonary blood flow and complications that may require intrathoracic procedures. -
Q23.4– Hypoplastic left heart syndrome: A complex congenital heart defect that can lead to pulmonary complications requiring surgical management. -
Q25.1– Coarctation of aorta: May be associated with secondary pulmonary issues necessitating thoracic surgery. -
Q26.2– Total anomalous pulmonary venous connection: A congenital anomaly affecting pulmonary veins, often requiring surgical correction involving the lung lining.
Each diagnosis is clinically relevant as it may necessitate intrathoracic procedures, including removal of the lung lining, under anesthesia.
Related CPT Codes
| CPT Code | Description | Clinical Relationship |
|---|---|---|
00540 | ANESTHESIA THORACOTOMY PROCEDURES NOS | Used for anesthesia during unspecified thoracotomy procedures; may be an alternative to 00542 depending on the surgical approach. |
00541 | ANESTHESIA THORACOTOMY PX W/1 LUNG VNTJ | Used when thoracotomy procedures require ventilation of only one lung; can be used in similar clinical scenarios as 00542. |
00546 | ANES THORACOTOMY PX PULMONARY RESCJ W/THORACOP | Used for anesthesia during thoracotomy procedures involving pulmonary resection; may be used together with or as an alternative to 00542. |
00548 | ANES THORACOTOMY PX NTRATHRC PX TRACHEA&BRONCHI | Used for anesthesia during intrathoracic procedures involving the trachea and bronchi; related to 00542 when airway structures are involved. |
These codes are commonly used as alternatives or in conjunction with 00542 depending on the specific surgical procedure performed.
National Reimbursement Benchmarks
National mean rates for CPT code 00542 show that commercial payers such as Blue Cross Blue Shield, Cigna, and Aetna reimburse at significantly higher levels than UnitedHealth Group. The average commercial benchmark (BUCA) is $329.92, while UnitedHealth Group's mean rate is $65.54. Medicare data is not available in the input, so no comparison can be made.
Rate dispersion varies widely across payers. UnitedHealth Group has the tightest range, with a difference of $25.47 between the 75th and 25th percentiles, indicating relatively consistent rates. In contrast, Cigna exhibits the widest dispersion, with a $1,208.50 gap between the 75th and 25th percentiles, reflecting substantial variability in contracted rates. Blue Cross Blue Shield and Aetna also show broad ranges, while BUCA's dispersion is moderate.
The table and chart below present the full breakdown of national benchmarks for each payer.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska exhibits a wide range in reimbursement rates for CPT code 00542, with Blue Cross Blue Shield showing the largest spread between the 25th and 75th percentiles ($1,107.00 minus $761.60 = $345.40). In contrast, Aetna, Cigna, and UnitedHealth Group have much narrower spreads, with their rates clustered closely around the lower percentiles. This indicates that Blue Cross Blue Shield's rates are not only the highest but also the most variable among the major payers in Alaska.
When compared to national averages, Blue Cross Blue Shield and Aetna pay significantly more in Alaska, while Cigna and UnitedHealth Group 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 across the state.
Key Insights for Alaska
- Blue Cross Blue Shield is the highest paying payer in Alaska for CPT 00542, with a mean rate of $941.94, while UnitedHealth Group is the lowest at $75.12.
- The rate spread is substantial, especially for Blue Cross Blue Shield, with a 75th percentile of $1,107 and a 25th percentile of $761.60, indicating significant variability.
- Compared to national averages, Aetna and Blue Cross Blue Shield pay notably higher mean rates in Alaska, while Cigna and UnitedHealth Group pay lower than their national benchmarks.
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