Anesthesia Policy Page 1 of 9

Policy Name: Anesthesia

Anesthesia Unbundled Services Code List 2018

Effective: 01/01/2018

0213T

0214T

0215T

0216T

0217T

0218T

0228T

0229T

0230T

0231T

20550

20551

20552

20553

22520

22521

22523

22524

31505

31515

31527

31622

31645

36000

36002

36005

36010

36011

36012

36013

36014

36015

36120

36140

36400

36405

36406

36410

36415

36416

36420

36425

Anesthesia Policy Page 2 of 9

36430

36440

36600

36640

43752

43755

61055

62280

62281

62282

62284

62290

62291

62310

62311

62318

62319

64400

64402

64405

64408

64410

64412

64413

64415

64416

64417

64418

64420

64421

64425

64430

64435

64445

64446

64447

64448

64449

64450

64455

64461

64462

64463

64479

64480

64483

64484

64486

Anesthesia Policy Page 3 of 9

64487

64488

64489

64490

64491

64492

64493

64494

64495

64505

64508

64510

64517

64520

64530

64550

64553

64555

64561

64565

64680

64681

67500

69990

72275

72285

72295

76000

76001

77002

81000

81001

81002

81003

81005

81007

81015

82013

82270

82271

82800

82803

82805

82810

85345

85347

85348

90865

Anesthesia Policy Page 4 of 9

90887

90889

92511

92512

92516

92520

92543

92950

92953

92960

92961

93000

93005

93010

93015

93016

93017

93018

93040

93041

93042

93312

93313

93314

93315

93316

93317

93318

93320

93321

93325

93701

93740

93770

94002

94200

94250

94640

94660

94662

94664

94680

94681

94690

94760

94761

94762

94770

Anesthesia Policy Page 5 of 9

95812

95813

95816

95819

95822

95829

95955

95956

95957

96523

99024

99050

99051

99053

99056

99058

99060

99080

99090

99143

99144

99145

99148

99149

99150

99190

99191

99192

99195

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

99217

99218

99219

99220

99221

99222

99223

99231

99232

Anesthesia Policy Page 6 of 9

99233

99234

99235

99236

99238

99239

99241

99242

99243

99244

99245

99251

99252

99253

99254

99255

99288

99304

99305

99306

99307

99308

99309

99310

99315

99316

99318

99324

99325

99326

99327

99328

99334

99335

99336

99337

99339

99340

99341

99342

99343

99344

99345

99347

99348

99349

99350

99354

Anesthesia Policy Page 7 of 9

99355

99356

99357

99358

99359

99360

99363

99364

99366

99367

99368

99374

99375

99377

99378

99379

99380

99381

99382

99383

99384

99385

99386

99387

99391

99392

99393

99394

99395

99396

99397

99401

99402

99403

99404

99406

99407

99408

99409

99411

99412

99420

99429

99441

99442

99443

99444

99450

Anesthesia Policy Page 8 of 9

99455

99456

99460

99461

99462

99463

99464

99465

99466

99467

99468

99469

99471

99472

99475

99476

99477

99478

99479

99480

99499

99601

99602

99605

99606

99607

Anesthesia Policy Page 9 of 9

Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan

businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company,

Medica Self-Insured, and Medica Health Management, LLC.