Summary & Overview
CPT 01250: Anesthesia for Shoulder and Axilla Procedures
CPT code 01250 represents anesthesia for procedures on the shoulder and axilla that are not otherwise specified, serving as a critical billing code for anesthesiology services in surgical settings. This code is widely used across the United States, particularly in outpatient hospital environments, to ensure accurate reimbursement for anesthesia care during a variety of shoulder and axillary procedures. The publication covers major national payers including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, providing a comprehensive overview of payer coverage and policy considerations.
Readers will gain insight into the clinical context of 01250, including its typical use cases, associated diagnoses, and related procedural codes. The summary also highlights common modifiers relevant to anesthesia billing, such as QS for monitored anesthesia care and QX for certified registered nurse anesthetist services with physician direction. Additionally, the publication explores taxonomy classifications for anesthesia providers and outlines key ICD-10 diagnoses frequently linked to shoulder and axilla procedures. Benchmarks and policy updates are included to inform stakeholders about current trends and requirements in medical billing for anesthesia services. This resource is designed to support healthcare professionals, billing specialists, and policy analysts in understanding the national landscape for anesthesia coding and reimbursement.
CPT Code Overview
CPT code 01250 is used to report anesthesia services for procedures performed on the shoulder and axilla that are not otherwise specified. This code falls under the anesthesiology service type and is most commonly utilized in the outpatient hospital setting (Place of Service 22). It is designed to capture the professional work of anesthesia providers during a range of surgical interventions involving the shoulder and axillary region, ensuring appropriate documentation and billing for these specialized services.
Clinical & Coding Specifications
Clinical Context
A patient presents to the outpatient hospital with shoulder pain and limited mobility, possibly due to a rotator cuff tear, osteoarthritis, or a clavicle fracture. The orthopedic surgeon schedules a surgical procedure on the shoulder or axilla, such as arthroscopy or open repair. An anesthesiology provider administers anesthesia for the procedure, ensuring patient comfort and safety throughout. The anesthesia service is coded with 01250, which covers anesthesia for procedures on the shoulder and axilla not otherwise specified. The clinical workflow involves preoperative assessment, induction and maintenance of anesthesia, intraoperative monitoring, and postoperative care.
Coding Specifications
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Modifiers:
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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 the anesthesia service under the medical direction of a physician.
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Provider Taxonomies:
| Taxonomy Code | Specialty Description |
|---|---|
207L00000X | Anesthesiology |
207LA0401X | Pain Medicine (Anesthesiology) |
367500000X | Certified Registered Nurse Anesthetist |
These taxonomies represent providers specializing in anesthesia and pain management, including CRNAs.
Related Diagnoses
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M75.100: Unspecified rotator cuff tear or rupture of unspecified shoulder- Indicates a tear or rupture of the rotator cuff, often requiring surgical repair and anesthesia.
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S43.401A: Sprain of unspecified acromioclavicular joint, initial encounter- Represents an acute sprain of the AC joint, which may necessitate surgical intervention and anesthesia.
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M19.011: Primary osteoarthritis, right shoulder- Describes degenerative changes in the right shoulder, potentially leading to procedures requiring anesthesia.
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M19.012: Primary osteoarthritis, left shoulder- Similar to above, but affecting the left shoulder.
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S42.001A: Fracture of unspecified part of right clavicle, initial encounter- Refers to an acute clavicle fracture, which may require surgical fixation under anesthesia.
Each diagnosis is clinically relevant as it may necessitate a procedure on the shoulder or axilla, for which anesthesia is provided and coded with 01250.
Related CPT Codes
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29827: Arthroscopy, shoulder, surgical; with rotator cuff repair- Used for minimally invasive repair of rotator cuff tears. Often performed with anesthesia coded as
01250.
- Used for minimally invasive repair of rotator cuff tears. Often performed with anesthesia coded as
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23412: Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; chronic- Open surgical repair of chronic rotator cuff ruptures. Anesthesia for this procedure is reported with
01250.
- Open surgical repair of chronic rotator cuff ruptures. Anesthesia for this procedure is reported with
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20610: Arthrocentesis, aspiration and/or injection into a major joint or bursa- Used for aspiration or injection procedures in the shoulder joint. May require anesthesia, especially in complex cases.
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29826: Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty- Arthroscopic decompression procedures for shoulder impingement. Anesthesia is provided and coded with
01250.
- Arthroscopic decompression procedures for shoulder impingement. Anesthesia is provided and coded with
These codes are commonly used together in shoulder surgery workflows, with 01250 representing the anesthesia service for these procedures.
National Reimbursement Benchmarks
For CPT code 01250, national mean rates among commercial payers are highest with Cigna at $248.20, followed by Blue Cross Blue Shield at $230.53 and Aetna at $227.02. UnitedHealth Group is notably lower at $65.60. The BUCA average commercial mean rate is $150.14. Medicare data is not available in the input, so no comparison can be made.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Aetna shows the widest spread ($305.00), indicating substantial variability in contracted rates. Blue Cross Blue Shield has a tighter range ($112.75), while UnitedHealth Group is the tightest at only $25.17. Cigna's range is $259.00, and BUCA's is $157.50. This highlights that UnitedHealth Group's rates are the most consistent nationally, while Aetna and Cigna exhibit the greatest variability.
The table and chart below present the full breakdown of national benchmarks for CPT code 01250 by payer.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska demonstrates a significant rate spread for CPT code 01250, particularly with Blue Cross Blue Shield, where the difference between the 75th and 25th percentiles is $72.70. BUCA also shows a wide spread of $123.97, indicating substantial variability in reimbursement rates across payers. In contrast, Aetna and UnitedHealth Group have minimal spreads, with all percentiles clustered closely around $72, suggesting limited negotiation or variation in rates for these payers.
Compared to national averages, mean rates for Aetna, Blue Cross Blue Shield, and BUCA in Alaska are considerably higher, while Cigna and UnitedHealth Group are below their national benchmarks. The table and chart below present the full breakdown of payer-specific reimbursement rates in Alaska for CPT code 01250.
Key Insights for Alaska
- Blue Cross Blue Shield is the highest paying payer for CPT 01250 in Alaska, with a mean rate of $266.95.
- UnitedHealth Group offers the lowest mean rate in Alaska at $74.78.
- Mean rates for Aetna, Blue Cross Blue Shield, and BUCA in Alaska are notably higher than their respective national averages, while Cigna and UnitedHealth Group are below national benchmarks.
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