Key takeaways from this episode

• Physician coding for ureteroscopic lithotripsy does not change: report 52353 without a stent or 52356 with a stent, whatever equipment is used. The physician is paid the same whether the case is done in an ASC or an HOPD and whether a suction scope, suction sheath or neither is used; the only potential differentiator is modifier 22 when documentation supports additional time and effort.
• The facility now has four coding options depending on the equipment. 52353 (no stent, no suction), 52356 (stent, no suction), C8014 (lithotripsy with a suction-enabled ureteral access sheath, effective July 1, 2026) and C9761 (lithotripsy with a steerable suction catheter or suction-integrated ureteroscope, description amended for Q3 2026).
• If both a suction scope and a suction sheath are used, the facility reports only C9761. C9761 and C8014 are never billed together; C9761 is the higher-paying APC, so it is the one code reported.
• Q3 2026 HOPD national rates: C9761 pays $9,671.50, while C8014, 52356 and 52353 all pay $5,477.93. All carry status indicator J1, so only the highest-paying primary APC is paid for the day.
• The HOPD should still report the bundled device codes C1747 (disposable scope) and C1889 (sheath) with invoice cost so CMS can collect device data. Those codes are not needed in the ASC for Medicare and most commercial payers, because device data is collected at the HOPD level.
• Q3 2026 ASC national rates: 52353 and 52356 pay $2,729.66, C8014 pays $3,452.00 (an extra $722.34 for the sheath) and C9761 pays $6,612.45. C8014 and C9761 are status J8 (device-intensive); 52353 is A2 and 52356 is G2.
• The 2027 proposed rule raises the C codes but trims 52353/52356 in the ASC. Proposed HOPD rates are $10,796.79 for C9761 and $6,292.10 for C8014/52356/52353; proposed ASC rates are $7,163.26 for C9761, $3,663.78 for C8014 and $2,680.86 for 52353/52356, with an overall 2.4% OPPS/ASC update and no coding-structure changes.
• Urologists should lead with the clinical case (stone size, anatomy, OR time, recovery) and back it up with these facility financials when requesting scopes and sheaths. Facilities make equipment decisions on business calculations, so bringing the payment picture gives you more options for the patient in front of you.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 295, recorded July 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

The amended C9761 and the new C8014

[00:00] Scott Painter: On this episode, new facility information for kidney stone scopes and sheaths. Stay tuned. Welcome to episode 295 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter, and we have some new developments for kidney stone scopes and sheaths. Mark, do you want to bring us up to speed? What's going on there, and what is CMS doing?

[00:33] Mark Painter: All right. We've been having a lot of discussion around C9761 over the past few months. And then we updated you that there was a change for July 1st, with the definition of code C9761 essentially being amended. Scott, maybe we could look up the new description, which handles really all scopes with suction capabilities in an ASC or an HOPD with code C9761, and then the introduction of the new code, C8014, for treatment of stones using a suction sheath. If we can read both of those definitions, we can get everybody on the same page.

[01:38] Scott: Okay. The new description for C9761 for Q3 2026 is cystourethroscopy with ureteroscopy and/or pyeloscopy with lithotripsy and ureteral catheterization for steerable vacuum aspiration of the kidney, collecting system, ureter, bladder, and urethra, if necessary, with use of steerable ureteral catheter or suction-integrated ureteroscope. So that's the C9761. The new code is C8014, and that description is cystourethroscopy with ureteroscopy and/or pyeloscopy with lithotripsy, including use of a suction-enabled ureteral access sheath with irrigation, and then in parentheses, if performed. So those are the two descriptions.

[02:44] Mark: Okay. Essentially, last time we talked to you we passed on that in treating stones we've got the physician coding, and with lithotripsy in the kidney or ureter we've got our 52353 and our 52356. So cystourethroscopy with ureteroscopy with lithotripsy for the 52353, and then 52356 is essentially the same description but with the insertion of a stent.

The coding for the physician is not changing moving forward, but the facility now has four different options for coding based on the equipment that's used to complete a lithotripsy treatment using a scope: 52353 if no stent was used and you didn't use any suction capabilities, 52356 for treatment with a stent insertion and no suction, C8014, which is the lithotripsy with the suction sheath, as Scott was talking about, and C9761 for lithotripsy with suction and a scope. Each one of those options is going to be the coding for the ASC or the HOPD, even though the physician is going to stick with 52353 or 52356, depending on whether or not they used a stent. That is what we talked about, and hopefully everybody's fairly clear on which codes to select and when.

What we didn't have when we talked about this before was the full reimbursement picture as it started on July 1st. So we thought we'd update you there. And additionally, since we talked to you last about these codes, we've got the proposed rule for next year, which provides some interesting information.

How OPPS groups payments for the HOPD and the ASC

We'll start with Q3 reimbursements. One of the important parts of looking at reimbursement, how it's calculated and what it means, is the statuses that are assigned to each one of these codes in the HOPD and then correspondingly in the ambulatory surgical center. Everything is married together, if you will, under the outpatient prospective payment system rules that were created by Medicare.

These are essentially group payments, and we've maybe talked about this a little bit before. What happens is the procedures that are performed in an outpatient hospital setting or in an ASC are grouped into specific categories. There are eight different categories in urology for all of the procedures that urologists do that are assigned to these group payment codes for the ASC and the HOPD under OPPS.

What Medicare does to determine how the ASC is paid relative to the hospital outpatient department is take a look at a percentage drop, essentially, in two different sides of the equation. One is the payment for the actual devices that are used, which basically in a marketplace cost the same thing in the US. The second piece is the general overhead and the cost of staff, which is projected to be lower in an ASC versus an HOPD. So ASC payment rates are somewhere around 40 percent, as a starting point, of what the HOPD is, but that varies based on several different rules and groupings as they assign things into the OPPS system for ASCs.

Q3 2026 HOPD rates and the J1 status indicator

We're going to start off talking about the HOPD. When we look at the HOPD payments for Q3, that's July 1 through the end of September, three months. Right now the HOPD gets a payment for C9761 of $9,671.50. That's the HOPD rate. Now, just like the physician fee schedule, there are adjustments for different locations, although they're a little bit different as to how they refine those adjustments. Different hospitals will get paid different rates based on the adjustments for geography and a few other considerations, so we're just going to give you the national rate.

The C8014, the 52356, and the 52353 payments to the hospital for Q3 are all the same and set at $5,477.93. Each one of them is assigned a status indicator of J1, which basically means that it is a primary APC, and everything that's done on the same day is rolled into that one code if it's the highest paying. They're going to pay just one of those. If you use a suction scope and/or a disposable steerable scope and a sheath, only one is going to get paid in that setting. So when you bill for the C codes, if you're using a disposable steerable scope and a sheath, you actually would not report more than one code.

You'd just report the C9761 for the scope that has suction capabilities that was used, because that is the highest APC that is assigned in the HOPD. You would never report both, even though you may have used a steerable scope with a suction sheath. You would only report one of those C codes, and the payment to the hospital would be based on that C9761, so the $9,671.50, and I'm sure it's just coincidence that it almost matches the C9761. So that's the jumping-off point.

Reporting the bundled device codes C1747 and C1889

[11:02] Scott: Do you want to bring up now the device-intensive codes, the other codes that you would include on the HOPD, or do you want to talk about that in a minute?

[11:13] Mark: No, we should do that, because both the C8014 and the C9761 involve devices that they are trying to track because of their cost relative to the overall payment. The hospital would also report the equipment that was used. So even though C1747, which is for the disposable scope, is now considered bundled, you would still report the C1747 if you were a hospital outpatient department billing for C9761 or C8014. If you're using a sheath for the treatment, you're going to report the C1889. There are all these numbers, and I'm sorry for those of you who are driving. So the HOPD would report both of those additional codes if a device, either a sheath or a scope or both, was used. You're going to report those additional C codes even though they're not getting paid.

They're going to be listed as bundled, but CMS would like to collect that data as well as the cost. So a lot of times when you are submitting the C1747 and the C1889, you would submit the invoice cost along with the claim so CMS can continue to collect that data, because they have a device-intensive modifier as well as the J1. That's a piece of the consideration that you want to talk to your hospital about, because there are offsets and calculations that happen in the future based on the data that they collect.

Q3 2026 ASC rates and status indicators

Now, when we move to the ASC, and that's the main reason I'm bringing this in, because I imagine the majority of you are not actually coding and billing for a hospital outpatient department. But if you're talking to the hospital outpatient department, you'll want to talk to them about that. It actually has more of an impact when we go to the payment rates that are set for the ambulatory surgical center. When we look at the ASC, the payments for Q3 for the 52353 and the 52356 are the same. They're paid at $2,729.66 at the national level. C8014 reimbursement is set at $3,452.00. So unlike the hospital, which gets the same payment rate for all three of those codes, the ASC actually gets paid an additional $722.34 for the sheath that is now part of C8014.

The payment for C9761, because it's actually assigned to a higher APC, which we saw in the higher payment in the hospital outpatient department, is going to be $6,612.45. That's all based on the device inclusions, and we see that in the status indicators for those particular codes. Both C8014 and C9761 are assigned a J8, or a device-intensive procedure. Now, because all of these costs are calculated under the hospital outpatient department when it comes to devices, you do not, in an ASC setting, for Medicare and for the majority of commercial payers, need to submit the C1747 or the C1889 and the associated invoice. They're not collecting that data at the ASC level. They're collecting it at the HOPD level. So that's a little bit different.

Then I'm going to give you the status indicators for 52353 and 52356 and explain a little bit about those, because it's going to make a difference when we move to talking about next year. The status indicator for 52353 is an A2, and that is because that code was in existence when we started using APCs, and they did some crosswalking to balance out some of the site-of-service differentials. They're taking a look at both the physician fee schedule and the OPPS to come up with an adjusted weight, and that then is multiplied by the conversion factor for the ASC to come up with the payment price. And then 52356, because it's a newer code, is assigned a status of J2. Also a site-of-service differential. Medicare really kept those different, not because they're calculated much differently, but to indicate that there were different points in time those were added to the system.

[17:48] Scott: That was the G2, not J2.

[17:51] Mark: Oh, sorry, G2. Thank you on all of that. So those are, number one, why they're paid the same. The calculation works the same. It's based on a single APC adjustment from the hospital setting to the ASC. And based on that hospital adjustment, the actual APC that's assigned to 52353 and 52356 for the last couple of years has been 50 percent of the HOPD rate. So that's how we calculated those numbers. It's slightly higher than the 40 that happens elsewhere. That's where we sit today in Q3 with all of those numbers. I'll stop there before we get into the proposed rule and what we're seeing for next year.

How a urologist should use this when talking to the facility

[18:53] Scott: All right. I have a quick question for you from a different perspective. A lot of these apply to the ASC, and the information that you're providing is good information about the payment that the HOPD and the ASC receive. This is important for urologists because a lot of the urologists out there may not necessarily have an interest in the ASC or the HOPD, but they do have the influence, or can suggest or request scopes and sheaths. So when we're looking at all this, it's important for urologists to understand when they're talking to the various facilities they're performing these procedures in. And Mark, I know it's always confusing with the facility payments and the C codes and all that. If you're a urologist, what do you find important in how to talk to your facility using this information?

[20:12] Mark: Of course, the HOPD and the ASC are going to be driven by their business calculations. Because they're a step away from the patients, they're going to be more concerned about whether or not these things make sense financially, maybe even more so than the clinical side, or at least from some perspective. What clinically is going to drive them is not as important as it is for you as a physician. And of course, you as a physician aren't going to see much of a difference based on the use of this equipment. The codes are 52353 and 52356. Whether you use a sheath, a suction sheath or a catheter or a scope or any of those things, you're getting paid the same.

Most physicians are looking at it from the standpoint of what's the best treatment for my patient, and that could include things like: is this going to be a shorter time period in the OR? Is it going to be a longer period of time in the OR? Am I going to get a cleaner kidney? What am I trying to do? Is my patient going to recover more quickly? All things that could make a difference on your QPP. So there may be a reimbursement impact somewhere down the road, but generally the focus is on care and what makes the most sense for that patient. So, translating from the clinical side, which of course you always want as the lead argument as you're going in, you want to be able to demonstrate to the facility that the financials make sense as well.

And then, of course, for those of you that own ASCs, you're wearing both hats, looking at both the financial impact to the ASC as well as the impact to you and what you do procedurally. So it is important, I think, to understand those things as you're thinking about: am I going to use equipment? Which equipment am I going to use? What equipment works best? And ultimately, can each patient follow the same set of protocols, or are you going to have different patients that need different things? What I'm seeing is stone size, the patient's health, the patient's anatomy for that matter, and whether or not they can accommodate a larger French scope. All of those things are going to make a difference on what type of equipment you're going to request. If you've got the arguments from the financial side demonstrating to your facilities why all of these make sense, that's going to give you more options based on the patient's condition and what you think is the best tool to use for the job.

[23:37] Scott: We've heard that some urologists have started using not only the steerable suction scope but also going with the sheath as well. So they're doing both a disposable suction sheath and the scope with suction. That's another interesting twist. Obviously, if you do that, the facility only bills the C9761, even though the scope and the sheath were used. That's a clinical decision, again, based on stone size and your patients. If that works better for you as a urologist, then that's a discussion. But just know that's how that's billed: you can't bill the C9761 with the C8014. The facility can't bill that. Ray, did you have any questions or comments?

[24:35] Dr. Ray Painter: No, you made the point clear. You do have to be involved, because they have to buy your equipment.

What the 2027 proposed rule does to these rates

[24:46] Scott: All right. Let's hear about next year. What's proposed?

[24:50] Mark: As a general proposal, Medicare has proposed a standard-for-them 2.4 percent increase in the HOPD and the ASC rates. That's across the board. They're also proposing a number of other very significant changes in how 340B drugs are being used. They're putting more services available to be performed in the ASC by continuing the three-year phaseout of the inpatient-only list, and they're adding more services to the covered procedure list in the ASC.

The current CMS is really focusing on trying to drive care to other sites of service and to level out some of those site-of-service differentials. Now, I definitely don't agree with the way they're approaching a lot of these, because on the other side of the coin, they are making significant moves to try and save money in Medicare spending under the guise of protecting patients from Part B premium increases. There's all sorts of activity that we're seeing around that big push to save more money in Medicare, and we'll leave a lot of that for another day. But they've definitely dialed it up to eleven and a half for fraud, waste, and abuse, which we're all feeling the pinch on. They're also, for next year, adjusting some of the scaling methodology that they're using for comparisons of HOPD rates to the ASC.

You'll see this reflected a little bit when we go through the numbers proposed for our four codes for next year. In the HOPD for 2027, they're proposing C9761 has a national rate of $10,796.79. That's an increase from today's 2026 rates. They're also proposing that C8014, 52356, and 52353 are placed into the same payment APC. That's going to go up to $6,292.10. So those are scaling up based on the general overall percentages. In the ASC, we found things to be very interesting.

The cost-of-device increases are flowing through in the proposed rule. So C9761, which is going to continue to be status J8, is going to be paid at $7,163.26. That's going up significantly. And then the C8014 is going up to $3,663.78. They didn't propose any more changes in the coding structure, so all the coding is going to be the same next year, but we are getting an increase, and not an insignificant bump, in the cost for each one of those procedures going into 2027. What was interesting as we were going through all of this is that 52353 and 52356 for the ASC are actually going down by a couple of percentage points, to $2,680.86.

That is where my comments about the status assigned in the ambulatory surgical center are very important, and it has been affected by the scaling number that Medicare uses to crosswalk payments in the hospital outpatient department to the ASC. It's not a huge drop overall, but it is a drop that they're proposing for the payment of 52353 and 52356 for 2027.

[30:01] Scott: From a urologist's perspective, we haven't seen what the payment difference, if there is going to be one, for 2027 is yet. We haven't seen that information come out. This is strictly the facility payment that you're talking about.

[30:21] Mark: It is, yes. We're hoping that today or sometime next week we'll see the proposed rule for 2027's physician fee schedule, but we have not yet seen that, so we don't know exactly what's going to happen to those relative values or to the fee schedule. We do expect it to go down when we see it, because we lost our 2.4 or 2.5 percent one-year temporary bump to the conversion factor, and we're back to budget neutrality. But we'll see what happens next week with that.

[31:03] Scott: Sounds good. So stay tuned on that one. Ray, any comments, questions?

[31:09] Ray: Just to clarify, Mark, you didn't suggest in any way that the payment for a physician was going to be any different in the ambulatory surgery center or in the hospital setting, right?

[31:30] Mark: Regardless of whether they perform the procedure in the ASC or in the outpatient hospital department, the physician gets paid the same amount, and that is true. It's also the same regardless of what equipment gets used. The only potential differentiator in payment would be the 22 modifier, because a particular case, regardless of equipment, took additional time and effort, and your documentation supported the use of the 22 modifier. It's a good question.

Sponsor and final thoughts

[32:12] Scott: Yeah. It's really interesting, as we discuss this, going back to it's very important for the facility, but it's also important for the urologist to have the discussion when it comes to the facility side if they're making decisions for what equipment you're using. All right. That was a long one, and a lot of information that you threw at them. Let's go ahead and wrap this episode up. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. All right, let's get some quick final thoughts. Mark, what are your final thoughts?

[33:00] Mark: All of these discussions that we've had in the past few weeks have, I think, brought to light a little bit more, I don't know if it's clearly, but certainly more to the forefront, that we've got different parts of the system that affect how we treat patients and how all of this gets navigated through this crazy system that we're in. And I will have to say that what was once crazy is even crazier now, as we're seeing shifts in prior authorization, takebacks, audits, RAC audits, UPICs. Everything is dialed up right now, as I mentioned before. And everybody is, I think rightfully, a little bit more on edge in looking at the margins that are out there as the pressure is really increasing to provide more for less or the same amount.

In the end it's less to do more. We've talked about this before in other cases: essentially physicians are seeing one-third more patients and taking home about the same gross income over the past twenty years, which is crazy. And we're all feeling the pinch. When I say we, I mean from the administrative side, the coding side, the physician side. It puts everybody a little bit more on edge, and certainly that's coming through sometimes, I think, in the way we deal with each other. So it's important to take a step back and look at all this stuff clinically.

As Ray says routinely, we may not be where we want to be or where we think we should be, but we are where we are. So we're all trying to navigate this system as best we can. Preparing and understanding where everybody's pressure points are when you're advocating for your patients, hopefully this helps a little bit, at least in one little area. But it's important to give those considerations to everyone and to really understand what you're talking about as you're advocating for the patient and for the treatment that you feel is best for that particular patient.

The other thing I'll put in place is, with the increase in prior authorizations and everything related to that pre-procedure work, it's important, as we've seen a lot of prior authorization fails and write-offs, to give your staff the time that they need to execute all of the prior authorization requirements, dot your I's, cross your T's, double-check your contracts. All of that has just become so much more important. And the team aspect of billing, from not only the physician office but now inclusive of the ASC and the HOPD, from start to finish, and by start I mean prior to seeing the patient, you're really going to have to spend that time to get ahold of that, or assign expertise within your practice so that at least somebody has the capability to make the arguments that you think should be made for your patients. So divide and conquer, assign, and work together to make sure that you're providing the care you really want to provide to your patients.

[36:59] Scott: Ray, final thoughts?

[37:02] Ray: Nothing to add.

[37:05] Scott: All right. I'll just remind you that the Urology Advanced Coding and Reimbursement Seminar registration is open. You can go to prsnetwork.com, and right there on the homepage is a Seminar Information and Registration button. Also, the PRS Coding and Reimbursement Hub is up and running, and all this information that we are talking about with these codes and the kidney stone scopes and the coding associated with it is going to be on the hub. It will be reflected not only on the kidney stone page but also on the products that are related to treatment of the kidney stone, so the scopes and the sheaths, and you'll be able to see the individual discussions on that. You can go to prsnetwork.com/urologyhub for the information on different urology categories as well as products for treatment of those categories. All right. That's all we have for today. Thank you all for listening. Take us out, Ray.

[38:11] Ray: Happy coding and billing.

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