General concept: Choose CPT based on what you did (ureteroscopy/pyeloscopy, lithotripsy, stent, etc.).

Common ureteroscopy/lithotripsy codes (examples)

• 52353 – Ureteroscopy with ureteral/renal pelvic lithotripsy
• 52356 – Ureteroscopy with lithotripsy and indwelling ureteral stent insertion

Documentation language that helps:

• State lithotripsy performed (laser, etc.).
• Stent usage (placed vs not placed; laterality if relevant).
• Describe stone burden/location and outcome (residual fragments, stone-free intent, etc.).
• Describe aspiration/evacuation workflow (e.g., suction via access sheath system) clearly, scope size and type/make.

• N20.0 – Calculus of kidney
• N20.1 – Calculus of ureter
• N20.2 – Calculus of kidney with calculus of ureter

• Scope & access: ureteroscopy and/or pyeloscopy performed.
• Lithotripsy performed: modality (e.g., laser) and primary stone location(s).
• Evacuation method: clearly describe fragment evacuation/aspiration technique used (e.g., active suction via access sheath system) including scope size and type. This documentation may be referenced by payer to determine appropriate reimbursement for the facility.
• Stent status: placed vs not placed, laterality if relevant.
• Results: residual fragments, stone-free intent, complications, and follow-up plan.

Practical point: If the physician op note is vague (“URS with suction”) you invite mismatches and avoidable denials/downcoding.

• Modifier Use

  • Modifier -59 (-XS) may be required when performing multiple stone procedures.
    Note: You may not report codes 52356 and 52353 on the same side with a -59 (-XS) modifier.
  • Modifier -22 is used when a procedure requires significantly more effort than usual.

    Example of Modifier 22 in Practice

    Scenario: Steerable Ureteroscopy with Suction Technology

    Standard procedure: Breaking stones with laser, relying on natural clearance.

    Enhanced procedure: Using suction to actively remove stone fragments, requiring additional laser work and extended scope manipulation.

    Documentation: “The procedure required 2 times the amount of operative time than the normal time to ensure a completely clear the kidney due to the number of stones, the structure of the stones resulting in irregular fracture and the anatomy of the kidney. Additional operative time was required to fully explore and evacuate stone burden, reducing post-op complications and risk of repeat stone formation.”

    Justification: This extra effort places the procedure in the statistical ‘tail’ of the standard bell curve, warranting higher reimbursement.

  • Modifiers -LT and -RT
    • Are required when a bilateral organ, such as the kidneys or ureters, is involved and a procedure is performed on only one side.
    • Are applied to unilateral procedures to differentiate between treatment on the left and right kidney or ureter.
  • Modifier -50 Bilateral
    • Use when identical service is provided on both the right and left during the same encounter.
    • Report “1” unit when using modifier -50 per current ANSI standards; fee may be increased to support expected increase in reimbursement.
    • Some payers may require alternative reporting including use of 2 lines with RT and LT on separate lines.
    • Check with payer for appropriate bilateral reporting.

• Global Period Awareness

  • Most kidney stone procedures have a 0-day global period. (Exceptions are the ESWL and PCNL procedures which have 90-day global periods.)

• Common Physician-Side Pitfalls

  • Underspecifying the work: “URS with suction” without clarifying lithotripsy, renal vs ureteral location, or outcome.
  • Stent ambiguity: stent placed but not clearly documented (or vice versa).
  • Inconsistent terminology: shorthand in the op note that doesn’t map to clean claims language.
  • Assuming facility edits don’t affect you: facility denials often trigger rebilling cycles and physician AR delays.

In most cases: ClearPetra use supports the documented ureteroscopy/lithotripsy service but does not change the primary facility procedure reporting pathway by itself. Facilities typically follow their standard URS/lithotripsy charging and coding processes.

HCPCS C9761 (facility-only): When facilities consider it + key risks

Why C9761 is being discussed in suction-assisted URS workflows: C9761 is a facility procedure code that describes cystourethroscopy with ureteroscopy/pyeloscopy, lithotripsy, and steerable vacuum aspiration performed with a steerable ureteral catheter. Some facilities have shared that they are billing C9761 in higher–stone burden cases and receiving payment when using suction-enabled access sheath workflows. Payment alone, however, does not eliminate compliance or audit risk.

How facilities frame the “fits the descriptor” argument

• All core procedure elements must be present: cystoscopy, ureteroscopy/pyeloscopy, and lithotripsy as performed. C9761 is a technology procedure code, not simply an alternative label for standard URS coding. It can only be reported by a facility.
• Steerable vacuum aspiration is the fulcrum: documentation must clearly support that vacuum aspiration is consistent with the descriptor including clear indication that the system was steerable and was performed in the collecting system—not just that “suction was used.”
• Workflow similarity (what some facilities assert): when a suction-enabled, navigable access sheath is actively used to evacuate fragments/dust and manage fluid, some facilities believe it aligns conceptually with the aspiration element described in the code and that the sheath functions as a catheter.

Risks (read this before billing C9761)

• Payer interpretation risk: payers may interpret C9761 narrowly and tie it to very specific devices or workflows. A facility’s internal interpretation does not control payer or auditor review.
• Audit and takeback risk: high-dollar and new-technology claims are frequent targets for review. Initial payment does not guarantee long-term retention of funds.
• Documentation mismatch risk: if the physician operative note describes “URS with suction” but the facility bills a code premised on a more specific steerable vacuum aspiration included in C9761, the inconsistency of documentation becomes a denial trigger.
• “Suction” alone is weak support: generic suction language does not reliably support the distinct elements implied by the C9761 descriptor—all aspects of the code must be met including ability to steer.

Important reminder: C9761 is distinct from device/supply reporting pathways. C9761 is an APC assigned to a device which as described by the code was used during the procedures. The code must correspond to physician services billed with CPT codes specified in billing guidelines. Although the APC tech code is not assigned a specific life expectancy, code status and payment should be checked regularly.

C9761 is not a Temporary-Pass-Through technology (TPT) code which is intended to be used for up to 2 years (may be extended by CMS for tracking or other purposes), so always confirm current payer policies and guidance before relying on any reimbursement assumptions.

ASC and HOPD (outpatient) diagnosis reporting: Report ICD-10-CM diagnosis codes that reflect the reason for the encounter/surgery and code to the highest level of specificity supported by the medical record (use all applicable characters; include laterality/associated conditions when available). In the outpatient setting, the first-listed diagnosis is used in lieu of an inpatient “principal diagnosis.”

For outpatient surgery (same-day surgery), code the reason for the surgery as the first-listed diagnosis even if the procedure is not performed due to a contraindication. If a definitive diagnosis is not established, do not code “probable/suspected/rule out” conditions—code the signs/symptoms or the condition(s) actually confirmed, and report additional diagnoses that affect care as secondary diagnoses.

Common Kidney/Ureter ICD-10 Codes:

• N20.0 – Calculus of kidney
• N20.1 – Calculus of ureter
• N20.2 – Calculus of kidney with calculus of ureter

Bottom line: Physician documentation of the procedure and equipment is key to facility reimbursement. Any codes billed by the facility must be supported by the documentation.

To reduce denials and rework, ensure the facility record clearly captures:

• Procedure elements: cystourethroscopy + ureteroscopy/pyeloscopy + lithotripsy performed (as applicable).
• Stone location/burden and outcomes: renal pelvis/calyces involvement and clearance intent.
• Fragment evacuation: clear statement of fragment evacuation/aspiration workflow (e.g., active suction via access sheath system).
• Stent status: placed vs not placed; laterality and device specifics per facility policy.
• Device/supply capture: ClearPetra device/supply documentation should match the supply log and charge capture record.
• Record alignment: physician op note + nursing + supply + charge master match the same story.

Why this matters: when records tell different stories, payers default to denial or downcoding.

Practical documentation protections (what helps in the real world)

• Be explicit in the facility record: describe the aspiration workflow (where it occurred—renal pelvis/calyces, what was aspirated—fragments/dust/fluid, and how suction was applied/controlled). Include devices used during the procedure.
• Align every record: physician op note, nursing documentation, supply log, and charge capture should all tell the same procedural story.
• Consider a brief claim or internal narrative: some facilities add a short explanatory note describing the steerable suction-assisted aspiration workflow, which can help demonstrate transparency if the claim is later reviewed.

Facility risk points (where denials happen):

• Facility documentation is generic (“suction used”) without clearly supporting what procedure elements were performed.
• Supply/device documentation is missing or doesn’t match the charge capture record.
• Physician op-note and facility record tell different stories (procedure elements, laterality, stent, outcomes).

Charge capture tips: common misses that trigger denials

• Vague “suction” wording: doesn’t support the full procedure narrative (and can create inconsistencies across records).
• Supply not documented: charge posted but not supported by the clinical record or supply log.
• Procedure mismatch: facility record reads like standard URS while other documentation implies different work elements.
• Assuming payer parity: commercial policies may not mirror Medicare outpatient treatment.

Operational best practice: add a brief post-op “billing attestation” line confirming the key performed elements and supplies used.