Example A — Ureteroscopy with laser lithotripsy + stent
Clinical: 70-year-old Medicare patient. Right kidney upper calyx stone treated with ureteroscopic lithotripsy; fragment basketed/removed; ureteral stent inserted.
Code(s): 52356.
Dx: N20.0 (kidney stone) or more specific code supported by documentation.

Example B — Two separate stones (distinct services)
Clinical: Two separate calculi treated on the right: lower ureter stone removed with ureteroscopy/basket; renal pelvis stone treated with lithotripsy; indwelling stent inserted.
Code(s): 52356 + 52352 -XS (when payer rules support separate reporting for distinct stones and documentation supports distinct work).
Dx: N20.1 (ureteral) and/or N20.0 (kidney), based on documented locations.

Example C — Suction-assisted ureteroscopy (facility coding differs by equipment)
Clinical: Left renal pelvis stone treated with laser lithotripsy using a suction-integrated single-use ureteroscope; stone fragments and dust actively aspirated; ureteral stent inserted.
Code(s): Physician reports 52356. Facility (HOPD/ASC) reports C9761 when all descriptor elements are documented; HOPD adds C1747 with the invoice price. If the same case had used a suction-enabled access sheath with a standard scope, the facility would instead report C8014.
Dx: N20.0 (kidney stone).

• Medical necessity: obstruction/hydronephrosis, infection, refractory pain, recurrent stones, failed conservative management
• Stone details: size/burden; single vs multiple; location and laterality
• Approach: ESWL vs ureteroscopy/pyeloscopy vs PCNL
• Stent: placed/exchanged/removed; reason and plan
• If suction/aspiration is used: describe the fragment evacuation workflow clearly (where performed, what was aspirated, how it was applied/controlled, and the device used) so facility documentation can align cleanly.

• Laterality (right/left) and precise anatomic location(s)
• Stone size/burden and number of stones treated
• Whether lithotripsy performed, whether basketing/removal performed, and whether distinct stones were treated
• Stent placement details and indication
• Scope type: state whether the ureteroscope was suction-integrated or standard — the facility cannot select between C9761 and C8014 without it
• Device identification: name each device used (scope and/or suction sheath) and its functional capabilities — not merely that "suction was used"

• Missing laterality: state right vs left kidney/ureter in both the note and the op report.
• Bundling/edit denials: when reporting multiple endoscopic stone services, clearly document distinct stones and anatomic locations; apply -59/-XS only when supported.
• Insufficient medical necessity: include obstruction/infection/pain/refractory status and why intervention is required now.
• Facility mismatch: vague "suction used" language can trigger denials when facility billing depends on more specific documentation elements.
• C9761/C8014 reported together: never — both are primary (J1) comprehensive codes; when a suction-integrated scope and a suction sheath are both used, report C9761 only.
• Device-code errors: HOPD Medicare claims missing C1747/C1889, or ASC Medicare claims including them — both patterns cause rework.
• C8014 not loaded by payer: commercial and Medicare Advantage plans may lag on the new code — verify policy/contract support or default to the supported code per payer instruction.

• 50590 – Extracorporeal Shock Wave Lithotripsy (ESWL)

• 50080 – PCNL for kidney stones up to 2 cm
• 50081 – PCNL for kidney stones larger than 2 cm

• 52356 – Ureteroscopy with lithotripsy and stent placement
• 52353 – Ureteroscopy with lithotripsy (without stent)

Reminder: Only one lithotripsy code per side may be billed (payer/edit dependent). Do not report 52356 and 52353 on the same side.

• 52320 – Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus
• 52330 – Cystourethroscopy with manipulation without removal of ureteral calculus
• 52352 – Cystourethroscopy with ureteroscopy and/or pyeloscopy with removal or manipulation of calculus

• 52332 – Cystourethroscopy with insertion of indwelling ureteral stent (e.g., double-J type)

• For the additional work associated with steerable vacuum aspiration or suction-assisted fragment evacuation, physicians may append modifier -22 to 52353/52356, or report the unlisted code 53899 (unlisted procedure, urinary system; paid by report), when documentation supports work greater than typically required.
• Add a short description of the extra work performed to Box 19 of the claim (or the EDI equivalent) to assist payer processing. Be prepared to provide clinical documentation if requested.

Important physician rule: C9761 and C8014 are facility procedure codes — physicians do not report them. Code based on the actual professional work performed: ureteroscopy/pyeloscopy, lithotripsy, stent placement, ureteral catheterization, stone manipulation/removal, or other documented services.

• N20.0 – Calculus of kidney
• N20.1 – Calculus of ureter
• N20.2 – Calculus of kidney with calculus of ureter
• N20.9 – Urinary calculus, unspecified

Tip: Select the most specific diagnosis supported by documented stone location. When stones are documented in both the kidney and the ureter, N20.2 is more specific than reporting either site alone.

• Medical necessity: obstruction/hydronephrosis, infection, refractory pain, recurrent stones, failed conservative management
• Stone size/burden: include measurement and number of stones when relevant
• Stone location: kidney (renal pelvis/calyces) vs ureter (proximal/mid/distal) + laterality
• Approach: ESWL vs ureteroscopy/pyeloscopy vs PCNL
• Stent details: placed/exchanged/removed; indication and plan
• Distinct stones: if billing multiple services, document separate stones and anatomic locations clearly
• Scope type (new for Q3 2026): state whether the ureteroscope was suction-integrated or standard, and whether a suction-enabled access sheath was used — the facility code turns on this equipment combination
• If suction/aspiration used: describe what was aspirated and where (renal pelvis/calyces vs ureter), how suction was applied/controlled, and the device name(s) to reduce facility documentation mismatch risk

• -59 / -XS may be required when distinct stone procedures are performed and payer edits allow separate reporting. Documentation must support distinct stones/anatomic locations. You may not report 52356 and 52353 on the same side with a -59/-XS modifier.
• -22 may be used when a procedure requires significantly more effort than usual. Document objective factors (operative time, complexity, stone burden, anatomy) and why additional work was necessary.
• LT / RT may be required for unilateral procedures on kidneys/ureters; document laterality clearly.
• -50 (bilateral) — use when the identical service is provided on both sides during the same encounter. Report "1" unit with modifier -50 per current ANSI standards; some payers require two lines with RT and LT instead. Check with the payer for appropriate bilateral reporting.

Scenario: Steerable ureteroscopy with suction technology requiring extended laser work and additional scope manipulation to evacuate stone burden.
Documentation concept: record extended operative time, increased complexity due to stone number/anatomy/irregular fracture patterns, and clinical rationale (reduce residual fragments, reduce repeat procedures).

• Endoscopic stone procedures (ureteroscopy, stent work) carry a 0-day global.
• ESWL and PCNL carry a 90-day global.
• Confirm using your MAC/payer fee schedule.

• Generic language: "URS with suction" is too weak to support facility C-code billing.
• Scope-type ambiguity: the op note does not say whether the ureteroscope was suction-integrated — the facility cannot pick between C9761 and C8014 without it.
• Prior authorization misalignment: when authorization is required, make sure the professional authorization (CPT® 52353/52356) and the facility authorization (which may require C9761 or C8014) are aligned.
• Record mismatch: physician note, facility record, supply log, and charge capture must tell the same story.

How to choose: the equipment combination drives the facility procedure code for suction-assisted ureteroscopy. For all other stone services (ESWL, PCNL, stent work), align charge capture to what was performed and your facility CDM mapping.

• C9761 – Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with lithotripsy, and ureteral catheterization for steerable vacuum aspiration; requires a steerable ureteral catheter or suction-integrated ureteroscope. Facility-only.
• C8014 – Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy, including use of a suction-enabled ureteral access sheath, with irrigation (if performed). Facility-only; effective July 1, 2026.
• 52353 – Ureteroscopy with lithotripsy (no suction equipment).
• 52356 – Ureteroscopy with lithotripsy including insertion of indwelling ureteral stent (no suction equipment).

• C1747 – Endoscope, single-use (i.e. disposable), urinary tract, imaging/illumination device (insertable). Packaged payment.
• C1889 – Implantable/insertable device, not otherwise classified — used for the single-use suction sheath. Packaged payment.

• Suction sheath + reusable standard scope: C8014 + C1889
• Suction sheath + single-use standard scope: C8014 + C1889 + C1747
• Suction-integrated single-use scope + suction sheath: C9761 + C1747 + C1889
• Suction-integrated single-use scope only (no sheath): C9761 + C1747

Submit the invoice price with the device codes; reimbursement on those lines is $0 (packaged), but reporting supports the device-intensive requirement and future rate setting.

• Facility charge capture: align the billed procedure to what was performed (ESWL, ureteroscopy/pyeloscopy, PCNL) and your facility CDM mapping.
• Supplies: capture stents, access sheaths, baskets, and other supplies per facility policy and payer packaging rules.
• Implants: document device specifics as required for your billing workflow.

• Reporting C9761 and C8014 together: never — both are J1/primary; report only one per case.
• Missing device codes on Medicare HOPD claims: report C1889 for the suction sheath (and C1747 for a single-use scope) with the invoice price.
• Device codes on Medicare ASC claims: not required and may trigger rejections or invoice requests from some MACs — check payer-specific instructions.
• Op note does not identify the scope type: without it, C8014 vs C9761 selection cannot be supported.

• N20.0 – Calculus of kidney
• N20.1 – Calculus of ureter
• N20.2 – Calculus of kidney with calculus of ureter
• N20.9 – Urinary calculus, unspecified

Facility tip: ensure the documented stone location supports the ICD-10 specificity selected. For outpatient surgery, first-list the diagnosis that best explains the encounter; do not code probable, suspected, or rule-out diagnoses unless payer rules and official guidance allow.

• Procedure performed: clear op note supports correct APC/grouping and device/supply charge capture.
• Laterality and location: right/left kidney vs ureter segment, and number of stones treated.
• Stent documentation: placed/exchanged/removed and device identifiers per facility workflow.
• Medical necessity: obstruction/infection/pain/refractory status supports admission/outpatient necessity and payer review.
• To support C9761: the record must show cystourethroscopy with ureteroscopy/pyeloscopy, lithotripsy, and use of a suction-integrated ureteroscope or steerable ureteral catheter with vacuum aspiration, identified by device name, with aspiration/evacuation of fragments, dust, debris, or fluid described.
• To support C8014: the record must show cystourethroscopy with ureteroscopy/pyeloscopy, lithotripsy, and use of a suction-enabled ureteral access sheath (with irrigation if performed), identified by device name, with a standard (non-suction-integrated) scope — if the scope was suction-integrated, C9761 applies instead.
• If aspiration/suction is used: document the workflow clearly (where it occurred, what was aspirated, how it was applied/controlled, and the device name) so the facility record can support the billed pathway.
• Record alignment: physician op note + nursing + supply log + charge capture should match the same story. When records tell different stories, payers default to denial or downcoding.
• Claim remarks: consider a brief note (Box 19 / UB-04 FL 80 or internal billing note) describing the suction workflow and device used, when supported by documentation and payer process.

• Packaging rules vary: supplies/devices may be packaged depending on payer and setting; device lines on C9761/C8014 claims pay $0 but must be reported in the HOPD.
• Site-of-service variance: ASC vs hospital outpatient vs inpatient drive different billing workflows, payment rates, and device-code reporting rules.
• New-code adoption risk: C8014 is effective July 1, 2026 — commercial payers, Medicare Advantage plans, and clearinghouse edits may lag. Confirm the code is loaded and payable before converting your chargemaster.
• Code-selection risk: billing C9761 when the scope was not suction-integrated (or C8014 when it was) is a mismatch auditors can spot from the op note. The scope type must be documented.
• 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.
• Edits/denials: ensure distinct stones and locations are documented when multiple services are billed.
• Operational best practice: add a brief post-op "billing attestation" line confirming the key performed elements, scope type, and supplies used.