Summary & Overview
CPT 01638: Anesthesia for Shoulder and Axilla Procedures
CPT code 01638 is a critical billing code for anesthesia services provided during surgical procedures on the shoulder and axilla. This code is widely recognized across the United States and is integral for ensuring proper reimbursement and documentation in hospital settings, particularly for inpatient care. The code is relevant for anesthesiology professionals, including physicians and certified registered nurse anesthetists, who deliver anesthesia during complex orthopedic and vascular interventions involving the shoulder and axillary regions.
Major national payers such as Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare cover services billed under CPT code 01638. The publication provides an overview of payer coverage, common billing modifiers, and associated clinical taxonomies. Readers will gain insight into the clinical context of the code, typical diagnoses linked to these procedures, and related CPT codes that may be billed in conjunction. The summary also highlights policy updates and benchmarks relevant to anesthesia billing for shoulder and axilla procedures, offering a comprehensive resource for understanding the national landscape of this service line.
CPT Code Overview
CPT code 01638 is used to report anesthesia services for procedures performed on the shoulder and axilla. This code falls under the anesthesiology service type and is most commonly utilized in the inpatient hospital setting (Place of Service 21). The code is essential for accurately documenting and billing anesthesia care provided during surgical interventions involving the shoulder and axillary regions.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult admitted to an inpatient hospital for a surgical procedure on the shoulder or axilla. The patient may have underlying vascular conditions such as atherosclerosis or peripheral vascular disease, which could necessitate surgical intervention. An anesthesiology provider administers anesthesia for the procedure, ensuring patient comfort and safety throughout the operation. The clinical workflow includes preoperative assessment, anesthesia induction, intraoperative monitoring, and postoperative care, often coordinated with the surgical and nursing teams.
Coding Specifications
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Modifiers:
QS: Monitored anesthesia care service. Used when the anesthesia provider delivers monitored anesthesia care 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.
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Provider Taxonomies:
| Taxonomy Code | Specialty Name |
|---|---|
207L00000X | Anesthesiology |
207LA0401X | Pain Medicine (Anesthesiology) |
367500000X | Certified Registered Nurse Anesthetist |
These taxonomies represent providers specializing in anesthesiology, pain medicine within anesthesiology, and CRNAs.
Related Diagnoses
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I70.203: Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs- Indicates bilateral lower extremity arterial disease, relevant for patients undergoing procedures due to compromised blood flow.
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I73.9: Peripheral vascular disease, unspecified- Represents general peripheral vascular disease, which may necessitate surgical intervention and anesthesia.
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I74.3: Embolism and thrombosis of arteries of the lower extremities- Refers to acute vascular events in the lower extremities, potentially requiring urgent surgical procedures.
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I70.213: Atherosclerosis of native arteries of extremities with intermittent claudication, right leg- Specifies right leg arterial disease, relevant for procedures addressing vascular compromise.
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I70.214: Atherosclerosis of native arteries of extremities with intermittent claudication, left leg- Specifies left leg arterial disease, relevant for procedures addressing vascular compromise.
Each diagnosis is clinically relevant as it may be the underlying reason for surgical intervention requiring anesthesia for procedures on the shoulder and axilla.
Related CPT Codes
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35371: Thrombectomy, open, including patch graft, if performed; popliteal-tibial or popliteal-peroneal-tibial- This code may be used when a surgical procedure involves removal of a thrombus from the lower extremity arteries, which could be part of a broader vascular intervention.
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37225: Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral- This code is relevant for endovascular or open revascularization procedures, often performed in patients with peripheral vascular disease.
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36245: Selective catheter placement, arterial system; each first-order thoracic or brachiocephalic branch, within a vascular family- Used for selective catheter placement during vascular procedures, which may be necessary for diagnostic or therapeutic interventions.
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93925: Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study- This code is used for non-invasive vascular imaging, often performed preoperatively or postoperatively to assess arterial flow.
These codes are commonly used in conjunction with 01638 when managing patients with vascular disease requiring anesthesia for shoulder or axilla procedures. Some may be alternatives or part of the same episode of care.
National Reimbursement Benchmarks
National mean rates for CPT code 01638 show that commercial payers (BUCA average) reimburse at $263.69, while UnitedHealth Group is notably lower at $65.53. Blue Cross Blue Shield and Cigna have the highest mean rates among commercial payers, at $500.71 and $553.30 respectively. Aetna's mean rate is $386.22.
Rate dispersion varies significantly across payers. Cigna exhibits the widest spread, with a difference of $776.00 between its 75th and 25th percentiles, indicating substantial variability in contracted rates. Blue Cross Blue Shield has a tighter range of $222.12, and UnitedHealth Group shows the narrowest dispersion at $24.75, suggesting more consistent rates. The table and chart below present the full breakdown of national benchmarks for each payer.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska demonstrates a wide spread in reimbursement rates for CPT code 01638, with Blue Cross Blue Shield showing the largest rate spread between the 25th and 75th percentiles ($208.25), while Aetna, Cigna, and UnitedHealth Group have minimal spreads, indicating consistent rates across providers. Compared to national averages, Alaska's mean rates for Blue Cross Blue Shield and BUCA are notably higher, whereas Cigna and UnitedHealth Group are below their respective national benchmarks.
The table and chart below present the full breakdown of mean rates and percentile values for each payer in Alaska, highlighting the significant variation in reimbursement across payers.
Key Insights for Alaska
- Blue Cross Blue Shield is the highest paying payer for CPT 01638 in Alaska, with a mean rate of $630.80.
- UnitedHealth Group offers the lowest mean rate at $74.78.
- Alaska's mean rates for most payers, especially Blue Cross Blue Shield and BUCA, are significantly higher than national averages, while Cigna and UnitedHealth Group are below national benchmarks.
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.