CPT 01992: Under Anesthesia for Other Procedures

What is CPT Code 01992?

CPT 01992 is used for anesthesia services provided during diagnostic or therapeutic nerve blocks involving the spinal cord, often for pain management procedures like epidural steroid injections. It applies when a qualified health care professional other than the proceduralist delivers monitored anesthesia care, regional, or general anesthesia to support patient comfort during interventional pain procedures.

This code is typically reported when the patient is high-risk (e.g., chronic pain conditions, severe cardiopulmonary disease, or requires a prone position) and the procedure requires anesthesia beyond local or moderate sedation. Proper use of 01992 CPT code depends on medical necessity, clear documentation, and accurate billing practices.

CPT code 01992 is often used in anesthesia for diagnostic or therapeutic nerve block procedures involving the spinal cord.

Documentation requirements

To support the use of CPT code 01992, healthcare providers must document key elements that justify the need for separate anesthesia services during interventional pain procedures, pain management services, or therapeutic nerve blocks.

• Procedure performed: Specify the diagnostic or therapeutic nerve block or pain procedure involving the spinal cord.
• Anesthesia type: Indicate whether monitored anesthesia care, regional anesthesia, or general anesthesia was provided.
• Provider details: Note that a qualified health care professional, different from the proceduralist, administered the anesthesia care.
• Anesthesia time: Record start and end times to ensure accurate billing.
• Medical necessity: Describe why local anesthesia or moderate sedation was insufficient, such as chronic pain conditions, prone position, or severe cardiopulmonary disease.
• Physical status and risk factors: Document high-risk conditions or advanced cardiopulmonary disease that justify separate anesthetic management.
• Patient response and monitoring: Include notes on patient comfort, vital signs, and any complications managed during the session.
• Medical record and coding compliance: Ensure the medical record supports billing and aligns with anesthesia coding and American Medical Association guidelines.

Documentation should explain why the patient is not a candidate for cases involving minimal anesthesia risk, such as those covered under local anesthesia or moderate sedation.

Billing guidelines

CPT 01992 should be billed separately from the pain relief management procedure when a different physician or qualified health care professional provides anesthesia services. This applies when anesthesia care exceeds local anesthesia or moderate sedation, such as monitored anesthesia care (MAC), regional, or general anesthesia, especially for high-risk patients with chronic pain conditions or advanced cardiopulmonary disease.

Use appropriate ASA physical status modifiers and time units for accurate billing. If MAC is used, append modifier QS to indicate conscious sedation or deep sedation during procedures like epidural steroid injections or therapeutic nerve blocks. Documentation must clearly show medical necessity, such as interventional radiology procedures, prone positioning, or the presence of severe comorbidities.

Ensure compliance with anesthesia coding standards outlined by the American Medical Association, and maintain a detailed medical record supporting the clinical decision-making process for using CPT code 01992 in markedly invasive surgical procedures or intervertebral procedures requiring enhanced patient comfort and monitoring.