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
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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.