Chart Talk: Anesthesia Coding Conversations

CPT 00910 – Anesthesia for Lower Urinary Tract Procedures

Descriptor:
Anesthesia for procedures on the lower urinary tract; cystoscopy and urethroscopy (including ureteral catheterization)

Key Points:

– Body Region: Lower urinary tract (bladder, urethra, cystoscopy procedures, ureteral catheterization)

– Procedure Examples: Diagnostic cystoscopy, cystoscopy with retrograde pyelogram, ureteral stent placement (via cystoscopy), urethral dilation

– Surgical Approach: Transurethral

– Typical ASA Base Units: 3

Use When:
– The procedure is within the lower urinary tract only
– No major open/percutaneous surgical approach
– Not extensive reconstruction or complex pelvic surgery

CPT 00918 – Anesthesia for Transurethral Procedures; Complicated

Descriptor:
Anesthesia for transurethral procedures; complicated (e.g., TURBT, TURP, lithotripsy, complex stent work).

Key Points:

– Body Region: Lower urinary tract

– Focus: Complexity, surgical intensity, increased physiologic stress

– Procedure Examples: TURBT, TURP, laser lithotripsy, complex stone removal

– Surgical Approach: Transurethral with major resection/complexity

– Typical ASA Base Units: 6

Use When:
– Transurethral resection or more invasive/complex surgery
– Larger tumors, prostate tissue removal, or significant stone work

Quick Differentiation Table

Simple Coding Rule of Thumb

If the procedure is “scope-only,” diagnostic, or minor → use 00910.

If the procedure involves resection, tumor work, lithotripsy, or is complex → use 00918.