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.

• 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, and how it was applied/controlled) 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
• Any suction/aspiration workflow details (if used) to reduce facility mismatch risk

• 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.

• 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)

• N20.0 – Kidney stone (calculus of kidney)
• N20.1 – Ureteral stone (calculus of ureter)
• N20.9 – Unspecified urinary calculus

Tip: Select the most specific diagnosis supported by documented stone location.

• 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
• If suction/aspiration used: describe what was aspirated and where (renal pelvis/calyces vs ureter) 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.
• -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.

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).

• Many endoscopic stone procedures are often treated as 0-day global.
• ESWL and PCNL are often treated as 90-day global.
• Confirm using your MAC/payer fee schedule.

• 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.

Why C9761 is being discussed in some 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. Payment alone, however, does not eliminate compliance or audit risk.

• All core procedure elements must be present: cystoscopy + ureteroscopy/pyeloscopy + lithotripsy (as performed) and documentation supporting the aspiration element. C9761 is a technology procedure code—not simply an alternate label for standard URS charging.
• Steerable vacuum aspiration is the fulcrum: documentation should clearly support that aspiration workflow is consistent with the descriptor—not just “suction used.”
• Workflow similarity (what some facilities assert): when a suction-enabled, navigable system is actively used to evacuate fragments/dust and manage fluid, some facilities believe it aligns conceptually with the aspiration element described in the code.

• Payer interpretation risk: payers may interpret C9761 narrowly and tie it to very specific devices or workflows.
• Audit and takeback risk: higher-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 is generic (“URS with suction”) but the facility bills a code premised on a more specific steerable vacuum aspiration concept, inconsistency becomes a denial trigger.
• “Suction” alone is weak support: generic suction language does not reliably support the distinct elements implied by the C9761 descriptor.

Important reminder: C9761 is distinct from device/supply reporting pathways. Code status and payment should be checked regularly. Confirm payer policies and facility compliance guidance before relying on any reimbursement assumptions.

• N20.0 – Kidney stone
• N20.1 – Ureteral stone
• N20.9 – Unspecified urinary calculus

Facility tip: ensure the documented stone location supports the ICD-10 specificity selected.

• 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.
• If aspiration/suction is used: document the workflow clearly (where it occurred, what was aspirated, and how it was applied/controlled) so the facility record can support the billed pathway being used.
• Record alignment: physician op note + nursing + supply log + charge capture should match the same story.

• Packaging rules vary: supplies/devices may be packaged depending on payer and setting.
• Side-of-service variance: ASC vs hospital outpatient vs inpatient may drive different billing workflows.
• Edits/denials: ensure distinct stones and locations are documented when multiple services are billed.
• C9761-specific risk point: if a facility considers C9761, vague “suction used” wording is a common mismatch trigger—documentation should reflect the full story being billed.