Summary & Overview
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.
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 |