CPT 00916: Anesthesia for Transurethral Bleeding Control
CPT code 00916 designates anesthesia services for procedures addressing bleeding control after removal of tissue accessed through the urethra. Nationally, this code captures perioperative anesthesia support during genitourinary procedures where hemorrhage control is required following transurethral tissue extraction. It is relevant to anesthesiology and perioperative service planning because these cases often demand tailored anesthetic techniques and intraoperative hemodynamic management.
Key payers covered in this summary include Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare. Readers will find a concise explanation of the clinical context for the code, typical sites of service, and how this code relates to nearby CPT anesthesia codes for genitourinary and endoscopic procedures. The publication outlines the clinical scenario captured by the code, common billing considerations, and comparisons to related anesthesia codes to aid coding accuracy and claims grouping.
This overview is intended for national audiences including billing professionals, anesthesiologists, and health policy analysts seeking clear context on when CPT code 00916 applies, which clinical situations it represents, and what to expect in terms of service setting and procedural intent.
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Billing Code Overview
CPT code 00916 describes anesthesia services provided for a patient who requires bleeding control following removal of tissue accessed through the urethra, the natural opening for urine outflow. This procedure involves managing anesthesia during a genitourinary operative intervention focused on controlling hemorrhage after tissue extraction.
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Service type: Anesthesia for genitourinary procedure addressing post-removal bleeding control
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Typical site of service: Operative suite or ambulatory surgical center where endoscopic or transurethral tissue removal procedures are performed
Clinical & Coding Specifications
Clinical Context
A 68-year-old male with a history of benign prostatic hyperplasia presents with hematuria and urinary retention following outpatient transurethral resection of prostate (TURP) performed earlier the same day. The patient is returned to the operating room for control of bleeding from the prostatic fossa accessed through the urethra. The anesthesiology team provides monitored anesthesia care or general endotracheal anesthesia per airway and comorbidity assessment. Typical workflow includes preoperative evaluation in the preoperative holding area, intraoperative management during cystoscopic inspection and coagulation or fulguration of bleeding prostatic tissue via transurethral approach, and postoperative handoff to PACU with ongoing monitoring for bleeding, hemodynamic stability, and urinary drainage. Expected site of service is an operating room in an ambulatory surgical center or hospital where endoscopic transurethral procedures are performed.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
23 | Unusual Anesthesia — Generally not expected with the procedure | Use when general anesthesia is required for a procedure normally done with local/regional anesthesia due to patient condition or surgical complexity |
62 | Two Surgeons | Use when two surgeons with distinct skills are required for the transurethral procedure |
50 | Bilateral Procedure | Use when identical procedures are performed bilaterally (rare for transurethral prostate procedures) |
78 | Unplanned Return to OR | Use when patient returns to the operating room for control of bleeding during the global period |
52 | Reduced Services | Use when the anesthesia service provided is reduced or less than typical for the procedure |
53 | Discontinued Procedure | Use when the procedure is started but stopped due to intraoperative circumstances |
22 | Increased Procedural Services | Use when work or complexity substantially exceeds the typical service for the procedure |
56 | Preoperative Evaluation Only | Use when only a preoperative evaluation was provided by the anesthesiologist |
59 | Distinct Procedural Service | Use to indicate a distinct procedure or service not normally reported together with the primary procedure |
AA | Anesthesia by Anesthesiologist | Use when anesthesia is personally performed by the anesthesiologist |
AD | Medical Supervision by Anesthesiologist | Use when the anesthesiologist medically supervises multiple concurrent anesthesia procedures |
AS | Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Service | Use when a qualified non-physician provides monitored anesthesia care under appropriate supervision |
QK | Medical Direction of Two, Three, or Four Certified Registered Nurse Anesthetists (CRNAs) | Use when the physician medically directs multiple CRNAs |
QS | Monitored Anesthesia Care Service | Use when monitored anesthesia care is provided and reported per payer policy |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207R00000X | Anesthesiology | Primary specialty providing anesthesia services for transurethral procedures |
208600000X | Pain Medicine | May be involved for complex pain management or regional analgesia planning |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
M23.50 | Chronic instability of knee, unspecified knee | Not directly related to transurethral prostate bleeding control; provided in input but unrelated to urologic anesthesia |
M25.561 | Pain in right knee | Not directly related to this urologic procedure; listed in input but clinically unrelated |
M25.562 | Pain in left knee | Not directly related to this urologic procedure; listed in input but clinically unrelated |
M17.11 | Unilateral primary osteoarthritis, right knee | Not directly related to transurethral bleeding control; may reflect comorbid musculoskeletal conditions affecting perioperative mobility |
M17.12 | Unilateral primary osteoarthritis, left knee | Not directly related to transurethral bleeding control; may reflect comorbid musculoskeletal conditions affecting perioperative mobility |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
00914 | Anesthesia for removal of prostate including use of an endoscope | Closely related: anesthesia code for transurethral prostate removal procedures such as TURP; similar operative field and anesthetic considerations |
00918 | Anesthesia for fragmenting, manipulation and/or removal of kidney stone including use of an endoscope | Related by anesthetic technique for endoscopic urologic procedures; illustrates comparable airway and positioning concerns |