Key takeaways from this episode

• C9761 is a facility code, not a physician code. The physician bills the ureteroscopy family (52351 diagnostic, 52352 manipulation/basketing, 52353 lithotripsy, 52356 lithotripsy with stent); the ASC or hospital outpatient department reports C9761 in place of 5235x when a steerable suction-assisted system is used.
• C9761 is a new-technology APC procedure code and is not going away; C1747 is a transitional pass-through device code that ends December 31, 2025. CMS decided in the final rule that single-use scope costs are roughly offset, so there is no separate C1747 payment in 2026.
• Both direct in-scope suction systems (Calyxo CVAC) and flexible and navigable suction sheaths (FANS) arguably meet the C9761 descriptor. The code requires cystourethroscopy with ureteroscopy and/or lithotripsy plus ureteral catheterization for steerable vacuum aspiration, using a steerable ureteral catheter; a steerable access sheath with a ureteroscope inside it can be argued to fit.
• Payers are paying C9761 for both system types today, but interpretation ultimately belongs to the payer and payment does not guarantee you keep the money. Putting the specific system in box 19 or the claim narrative is optional and may add some protection in an audit.
• Document the suction-assisted device in the operative note. The op note is what a reviewer reads, and it must support the facility's C9761 claim; if the case takes extra time, modifier 22 applies to the physician claim only, never to the facility's C9761.
• The ASC payment differential is real: roughly $2,500 for 52356 versus about $4,700 for C9761. Physicians who understand the facility economics can make the case for their surgery center to bring in suction-assisted technology.
• RAC audits and look-backs on high-priced new technology are aggressive right now. Get the CPT, HCPCS and diagnosis coding working together with the documentation before adopting new devices.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 257, recorded September 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network, and guest Dr. John Lin.

Welcome back, Dr. John Lin, and the Thriving Urology Practice group

[00:00] Scott Painter: On this episode: clearing the field about catheters that suck. Welcome to episode 257 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. We want to welcome back special guest Dr. John Lin. Thank you for joining us today. For those of you who don't know him, John is a solo practitioner in Gilbert, Arizona. John, welcome to the podcast. Thank you for joining us.

Dr. John Lin: It's always a pleasure, and I can't wait to bring more value to our audience.

Scott: All right. John was a founder of the Thriving Urology Practice Facebook Group, which is a group on Facebook that talks about all sorts of urology practice issues. John, do you want to tell everybody what they need to do to sign up if they haven't already become a member?

[01:00] John: As long as you have Facebook, you can sign up. So I'll ask you this: what if you could ask daily burning practice management, coding and billing questions at any time, and have that question answered by people who have successfully done it and lived it, so that you can easily navigate through the crazy world of urology? For example, you're wondering if you or your practice are being fairly compensated for taking hospital or ER call. Can you charge a credit card surcharge fee in urology collections? Those are some of the questions that people have actually asked in the Thriving Urology Practice Facebook Group. That is not all. You will make friends across the country who all share the daily conundrums and joys of urology. That's the Thriving Urology Practice Facebook Group. Join; it's free. Some members tell me it's the only reason they are on Facebook. Back to you, Scott.

[02:00] Scott: All right, very good. A great, valuable resource. Thank you, John, for that. Okay, let's get started on today's topic. Mark, do you want to frame the discussion we're going to have today? Really it's a facility discussion. You can go through the physician discussion first, but what we're really talking about is C9761. I'll turn it over to you.

Physician codes, C1747 and the C9761 new-technology APC

[03:00] Mark Painter: All right, so we'll start with number one. For the most part, when we're talking about C9761 we're talking about coding and billing for the facility. But I'm going to drop back first and talk about the professional payment side. When the physician is providing the service of laser lithotripsy of a stone, or manipulation and basketing of a stone, stent insertions, those types of things, we have CPT codes that describe those services: 52351 for the diagnostic, 52352 for the manipulation, 52353 for the lithotripsy, and 52356 for the lithotripsy with stent insertion, using a scope to do that. The physician is going to bill those codes.

The facility, in most cases, is going to use the same code to report the service, but Medicare created a couple of different pathways to allow for new technology adoption by ambulatory surgical centers and hospital outpatient departments. One of the pathways they created was the transitional pass-through codes, the TPTs. Those are specific to types of devices. They won't label them specifically for a brand-name device, but they'll create a category for that. We do have a TPT for a single-use scope used in the genitourinary system, and that's C1747. That is an add-on code for the actual disposable device, the single-use scope. That code has had its life and will be retired, or actually categorized as bundled, at the end of this year. So in 2026 there will be no payment for C1747. CMS, in their final rule, basically argued that the overall cost offsets are about the same. People are using them relatively evenly, or at least it doesn't appear to be a barrier overall, so they decided they weren't going to make an adjustment moving forward for the disposable scopes after the end of this year. This year, they have a device offset that does allow some additional payment based on the invoice cost, so that is a payable code if it's used in the appropriate circumstance.

C9761 is a different type of code, and this is something that we had confused in a previous discussion, so we want to make it clear: C9761 is a new technology APC, so it is actually a procedure code. Instead of billing 52356, if that's what the physician performed during the setting, if there was a steerable suction-assisted scope used during the procedure, the appropriate billing for the facility would be C9761. It pays a higher rate because there is a higher capital equipment cost, and the volume for the service isn't as high as, maybe, the use of a standard scope or a laser, those types of things. So it's a short-term payment that allows people to adopt that technology.

When that expires, what CMS could do is develop what they call a C-APC, which may require the facility to report one code or two codes, and a payment would be made based on an existing APC but at an adjusted rate. We've seen this happen in different situations, like we see with Photocure. The use of that technology, Cysview, which is considered a supply in certain circumstances, when it's reported actually changes the APC from a level two to a level three. It bumps it up another level to give that extra payment. Medicare is trying to put everything into similar buckets as they go throughout the payment process. So they start with a new technology APC, and then eventually they'll probably migrate it to some other payment, like a C-APC, or they'll assign it to a specific APC depending on the overall cost and how it is relative to the APC that it's finally assigned to.

Scott: All right, John, your thoughts, comments?

[08:00] John: This billing and coding stuff is certainly confusing. You have the physician doing the work, and there's a set of codes that we use, and now you have the facility needing to also be compensated for the expensive technology that is more efficient in clearing stones. So these are two different buckets that we have to contend with. For the physician, that's one thing, but we're talking about the ambulatory payment classification, APC, code of C9761. When talking about this, we definitely have to be clear in the definition of what C9761 is and how it can be appropriately used. So getting that clarification, I appreciate that very much, Mark. Getting that clarification is important so that surgery centers, and a lot of physicians and practices run surgery centers, have clarification regarding what that code is and how it is used. You made a subtle point: C1747, the disposable ureteroscope code, is a TPT code that is actually going away starting January 1st, 2026. But C9761 is an APC code that is not going away. So that is important.

Mark: Yeah, thanks for putting that in. I definitely was navigating a lot, and it's always helpful to have you translate what I say into English for everybody else.

John: My mind is very simple, so I have to think in very simple terms.

Scott: Ray, any thoughts on that?

Dr. Ray Painter: No, I think I even understand it now, Mark. Thank you.

Which scopes qualify: direct in-scope suction versus FANS

[10:00] Scott: All right. So now the question that we always get is: what scopes qualify? We've answered this, I guess, in the same way many times. But do you want to restate it? You've got the different scopes out there, and John, when we were having our initial discussion preparing for this episode, you put them in two different categories. Do you want to share with us what those categories are, at least how you define them and how they're defined? Then let's talk about what that means in the payment system.

[11:00] John: Okay. So the founders, the people who started all of this, is Calyxo with their CVAC system. They're the ones who applied and pushed for a new APC code, C9761. Initially, when Calyxo came out with their system, it was nothing but a catheter that you can move around into the different calyces to remove stones. They have an irrigation and then a large suction port in that steerable catheter. We should be clear on the definition; we'll go over that definition in just a second. So they came up with version one of the Calyxo CVAC. Of course, they're an innovative company, and they improved on that system. Instead of just a navigable sheath that you can turn externally, the current system they developed is an integrated ureteroscope with a separate irrigation system and a large-bore suction. So they can do both at the same time, or actually all three: they can see what they're sucking, they can irrigate around the large bore, and, if you can imagine, that fluid pushes the stones into this large-bore suction working channel, concurrently. All three things happening: seeing it, irrigating it and sucking it out. That's the current version of CVAC, which I think is an amazing development. So that's one bucket, and I call that direct in-scope suction.

On the other hand, you have FANS, flexible and navigable sheaths. There are several manufacturers of FANS, and I'll just name a few: there's the Dornier Hoover, Karl Storz, ClearPetra, Pusen and LithoPass, and I may have missed others, because it seems like every other day there's another manufacturer producing another navigable sheath. So those are the two different categories.

The conundrum is, okay, here's the definition. We need to understand the definition of C9761: cystourethroscopy with ureteroscopy and/or ureteroscopy with lithotripsy, and ureteral catheterization for steerable vacuum aspiration of the kidney collecting system, ureter, bladder and urethra if applicable, parentheses, must use a steerable ureteral catheter, close period. If you look at that definition of C9761, I think you can argue for Calyxo CVAC. Yes, they developed a product, they developed a technology, and it fits, because they're doing ureteroscopy, laser lithotripsy, ureteral catheterization for steerable vacuum aspiration of the kidney, using a steerable ureteral catheter. Well, I guess you can think of the large-bore access sheath as a catheter. On the other hand, in the FANS camp of things, you have the steerable sheath. The sheath itself is not steerable by itself, but you put a ureteroscope through that sheath and you're steering that sheath into the different calyces to perform the suction while the ureteroscope is seeing the stone, probably using a laser and breaking up the stone, while, either concurrently or separately, that larger-caliber steerable sheath is sucking out the stone.

So you have these two camps, the DISS and the FANS. I think they both fit the definition of C9761, to the dismay of Calyxo and the manufacturers and the founders. I think the way that the HCPCS code is developed, C9761, definitionally both fit. So I would be curious to hear what your thoughts are, Mark, regarding this.

Payer interpretation, box 19 and modifier 22

[15:00] Mark: There's certainly a reasonable argument, as you just made, that both fit. Ultimately, what we're stuck with is not necessarily our interpretation but the payer's interpretation as to what they're going to finally put into the processing of claims submitted with C9761. So I feel that we need to add that caution into the discussion: the payer has some say in that interpretation. But I also would agree, John, that so does the physician, or the entity that's billing this, in saying this fits this definition. So we've got, as we do in many things with reimbursement, a gray area with interpretation that eventually needs to be adjudicated somewhere.

Now, I will tell you that there are lots of folks that are using C9761 for both types of systems. Payments are being made for both types of systems with C9761. What I have not experienced yet are any reviews or any specifics that are there. I have found, with some additional research on all of this, that there are times when people are putting in box 19 exactly what system they're using, or putting it in the narrative, which may provide some extra protection, because essentially now you're telling the payer: this is what I'm using, this is the code I'm using. If you receive payment, you've got an even better argument for doing that. But it's not necessarily required. So that's the other side: another choice you may make or not make is reporting that additional clarification, because reporting it with nothing in the box, C9761 on its own, is getting paid if it is associated with a physician procedure code of 5235x, whichever one you're using.

I probably should also mention something we didn't mention up top: sometimes that effort of clearing all of the stone burden takes extra time, and physicians do take extra time using the suction-assisted devices for some of those cases. So for some of those we're using a 22 modifier. Again, that affects the physician billing but not the facility billing. There's no 22 that goes on to the C9761.

[19:00] John: I appreciate you discussing and sharing the conundrums of billing and coding when it comes to busting up large stones. You've got C9761 that is used by the facility, surgery center or hospital, and then you have the physician side of things. We want to make clear again that C9761 is for the facility and not for the physician. That is important to understand. You also illustrated, and we have said this numerous times in the past, in seminars and in podcasts, that you can certainly bill for it and you most likely will be paid, but that doesn't mean you won't be audited. And also, very importantly, just because you got paid doesn't mean you get to keep the money, because the payers can always come back and audit and disagree with your interpretation of C9761. That said, if I'm tasked, for that second-level or third-level appeal, with appearing in front of an administrative law judge to argue this case, I personally would feel very comfortable arguing for C9761 if you use a DISS or a FANS.

Why physicians need to understand the facility economics

[20:00] Scott: Yeah. I think the other piece of this, and why it's important for physicians to understand this, is when a facility is looking to purchase scopes for whatever they're doing, in this case large stones. What are they going to do with a large stone? What scope are they going to use? The physician may be asked what the different scopes are and what the billing side of things is. Just being able to have that understanding in their back pocket when they're having that discussion is important.

[21:00] Mark: Yeah. John brought up the point before that not every surgery center has the same approach to new technology and equipment. That's another business entity, even oftentimes for those that are wholly owned by physicians. It's a separate business entity that needs to monitor the economics of their business. So those decisions, and what you have available to you, actually depend on making sure that you have at least an idea of where the reimbursement is and how that fits for that business entity as well as your own. As you argue for patient care, which in the end is the goal of all of this, to provide the best patient care, if you've got these arguments available to you and you can have those discussions with your facilities, you may get the opportunity to use some of this advanced equipment, whereas the initial decision was no. Making that case for the economics on the facility side is the other piece, and that's one of the reasons we want to have these discussions, in addition to helping out those who are actually billing them. Understanding the whole picture is important.

[22:00] John: Yeah. Before I could use LithoPass in the surgery center, and I currently have no financial interest in the surgery center in which I perform almost all of my surgeries, before I even adopted LithoPass, I made sure the vendors were there, making sure that the surgery center understands how this process is going to work. I also understood the billing aspect, which allowed me to make the case: we should try this. Let me use this so I can clear the large stone out of the patient in one anesthetic. Much easier, much faster. Financially it makes sense to the surgery center, because I can get out of the surgery center faster and they can turn over the room for an additional case. And let's be frank, that is how they're going to make their money. This is an in-network surgery center. They are benefiting by having volume. So this allows more efficiency, but I can't ask them to lose money when they're using a Pusen or ClearPetra or LithoPass or CVAC. So it is important for me to understand what I have to do in my documentation. I outlined that this particular system is used, so that on the surgery center side, when they code for their procedure, they will be appropriately compensated, because I can't kill off the surgery center by making them lose money. If I want to serve my patients, I have to serve the patient and make sure that the surgery center is made whole. That is the fine line that we have to walk as urologists, and that's why I say this is such a crazy system that we work in, in urology and in medicine in general. We now have to be a surgeon, a physician, and a prudent business person for multiple heads.

[24:00] Mark: So true. Yeah, John, that point overall, the use of a particular device and the differentiated payment. Just to talk about the revenue side of the equation: a 52356 for a surgery center, the payment is roughly $2,500. At this point in time, the C9761 is $4,700. So there is that differential in there for the suction assistance and the steerable system. There's an extra payment in there, so as the entity looks at volume and everything, it can make a selection as to which system they want to use for larger stones, and they're going to run that calculation over time. You alluded to this, and I'll hammer it home again, maybe a little more clearly: if you're using a suction-assisted device, you do want to include that in the documentation of your procedure note, because that is the place that is going to be reviewed in any chart review. Accurate documentation of the device you're using should be in your operative note to support the facility billing C9761 if the suction-assisted device was used during the procedure.

Scott: Ray, comments?

[26:00] Ray: Well, Mark sort of stole my thunder. This is a high-level discussion, and I wanted to go back to the basic, and that's that your documentation is the thing that drives everything, including the payment. If I understand the two technologies, one fits the definition to a T, and the other technology actually provides the same function as the definition of the code, but your documentation has to show that it is the same duck if you want to get paid for it. The old saying: if it acts like a duck and quacks like a duck, it's a duck. Well, coding doesn't always fit the duck definition. But in this case, one is the duck and the other acts like a duck, and that's the reason both should be paid.

Sponsor, seminar and final thoughts from Mark

[27:00] Scott: All right, well, let's wind this episode down. 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/prs for specials for our listening audience. We want to thank everybody for listening today. One other thing I wanted to mention is that the Urology Coding and Reimbursement Seminar is coming up in December in Las Vegas, and in New Orleans at the end of January. We have discussions very similar to this in a lot of ways throughout the seminar, as questions arise on various topics. So one of the things we encourage is coming and attending one of the seminars. You'll see and get a lot of information that you aren't privy to on a day-to-day basis. There's a lot of information that John and Mark present, along with Marianne Desciose, bringing various perspectives, as well as the audience members bringing information in from across the country, sharing that and asking those questions. It's super important to get those different perspectives, get that information, and spend the time to really immerse yourself for two days in this coding and reimbursement world to set your practice up for the future. All right, let's get some final thoughts. We're going to let John have the final word. Let's start with Mark. Final thoughts.

[29:00] Mark: So we spent today talking about new technology and new things and how to code for those. One of the things that's been exciting in urology over the past several years is we've gotten a lot of new tech that's come into urology. We've gotten new drugs, new devices, new ways to treat things, new ways to diagnose, and that train is not slowing down. As you look at new technology and how it's going to be adopted in your practice, and where you're going to adopt it in your practice, we all know that the reimbursement side of the equation plays a key role, as does the appropriate documentation. We are spending a significant amount of time right now with a lot of our clients dealing with RAC audits and look-backs, and this is maybe one of the reasons I might be a little tighter than I have been in the past, because they are being very aggressive in their RAC auditing and their takebacks with this new technology, because a lot of it is fairly high priced. So it really does go back to documentation as the basis, following the rules, and really understanding the codes, not just the CPT but the diagnostic coding. All of that has to be working together, and the team that you have behind you needs to work together to make sure you can provide the best options for your patient as you see it and as you understand the information that's out there.

Some of the stuff that's new is great and works really well, and there's some we've learned more about over time and decided it's not as good as we thought it was originally. But that's part of the process, the evolution of care that we have in the United States. Ultimately, one of the things we discuss in the podcast, and also in detail at the seminar, is what new technology is out there and what the reimbursement positions are for Medicare and some of the other payers. We get to share that among people that use it, and we also get additional information from our Urology Pharma and Technology Pioneer group, from folks around the country. So we're continuing to try to stay up with the reimbursement side of the new technology that's out there to help you in your practice adopt and offer the best care you can to your patients, and we'll keep fighting for that. For those of you out there that would like to join us in the UPTP, the more the merrier, because it takes a village in this crazy world to find out what everybody's actually doing, not just the theoretical.

The Pioneer group, the urology hub and final thoughts from Ray and John

[32:00] Scott: Just to do a little interpretation: the Urology Pharma and Tech Pioneer Group is a group that we've put together that meets once a month, typically the second Tuesday of every month, and we discuss these new technologies. If you're interested in that, you can go to the episode page, prsnetwork.com/257, and there will be a link there to apply to join that group. That is an invitation group, so we are extending an invitation to our listeners. There will also be a link to register for the seminar there as well: prsnetwork.com/257. Okay, Ray, final thoughts.

Ray: Well, the discussions that go on behind the scenes to be sure that this payment information is correct are always fun, and always kind of interesting to listen to, because I can tell you that Mark and Scott and John, when he is with us, wipe out both gutters to be sure that you've got everything in the middle of the road. I can assure you that the team works very hard to give you accurate information. And Scott, you need to share with them how you're sharing this information, other than just the podcast.

[33:00] Scott: Yeah. If you go to prsnetwork.com/urologyhub, we're building this information out so that we can share information on specific categories as well as technologies. Right now we have information on kidney stones, upper tract urothelial cancer and urodynamics, and we're getting ready to add more topics the rest of this year. We're building a lot of these topics out, so you can always check that out at prsnetwork.com/urologyhub for information on our hub. We're trying to get all that information up and out and easy to digest. Okay, John, final thoughts?

[34:00] John: Look, I get it, urologists. You trained how many years to finally become a urologist. All you wanted to do is just take care of patients and do urology. But now you are having to learn this coding and billing BS. It's frustrating. Then you layer that on with prior auths, and sometimes after you perform the procedure you're being audited. It's extremely frustrating. But just think about how you were trained, how you used to do things. For instance, just a TURP or a ureteroscopy, bread-and-butter urology. Heck, for some of you who have seen my vasectomy videos, how you perform vasectomies. We don't do things the same way as we did back during residency. A famous person, Warren Buffett, has said the chains of habit are too light to be felt until they're too heavy to be broken. We are so used to just doing things the same way over and over again. It's imperative that we grow with technology. We grow with the changing rules of coding and billing.

Why are some folks in the US paying a lower percentage in taxes, whereas others simply pay whatever the government tells them they have to pay? The only difference between the two is that one knows how the rule is played, and the other just takes the blanket standard deduction. Understanding the rules, understanding what the payers want, understanding what the government wants when it comes to taxes, in our case what the payers want, and how you can use these rules to your advantage to serve your patients, is imperative in 2025, 2026 and beyond. It's no longer you fill out a piece of paper, the CMS 1500, and you mail that in for payment. Those days are gone. Things have become extremely complicated, and the folks and the practices that really win are the ones who understand the rules first and implement them. Those are the folks who take advantage, and those are the folks who will be able to leverage that knowledge to their advantage for their patients and for the practice. How do you do that? Mark and Scott have already said this: the Urology Advanced Coding and Reimbursement Seminar, the Urology Pharma and Technology Pioneers monthly virtual meetings, and this podcast. Those are some of the ways you can stay ahead of the game so that you can not only survive but thrive in the business of urology. Back to you, Scott.

Scott: Well said. All right, we will end this episode here. Thank you all for listening. Take us out, John.

John: Happy coding, everyone.

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