Key takeaways from this episode

• C9761 is a new technology APC that pays the facility far more than the standard lithotripsy APC. C9761 pays $6,612.45 in the ASC and $9,671.50 in the HOPD, versus $2,729.66 and $5,477.93 for the APC that groups 52353 and 52356.
• The whole dispute turns on the descriptor's requirement that the procedure "must use a steerable ureteral catheter." Manufacturers and facilities have argued that sheaths and suction scopes qualify as catheters, and the payer decides how that parenthetical is interpreted.
• AHA Coding Clinic says the CVAC system qualifies for C9761, but a navigable access sheath and a steerable suction access sheath do not. The AHA found all components of the code met with CVAC, including cystourethroscopy, lithotripsy, a steerable ureteroscope, pyelogram and stent placement, and found a sheath is not a steerable ureteral catheter.
• The AMA's unpublished opinion is that neither a vacuum-assisted access sheath nor a ureteroscope with vacuum meets the definition. In the AMA's view, if the device is not labeled a steerable ureteral catheter, it is not one.
• Noridian gave Karl Storz verbal support for ClearPetra under C9761 but has not published it, and its website stresses that codes are not product specific. The MAC and CMS have the final say on coverage and adjudication for each code.
• Before billing C9761 with a steerable suction scope or a sheath, get written payer confirmation. That means a written policy, contract language, or written confirmation from a payer conversation; CVAC is the only device with clear support today.
• Physician documentation has to name the device and state that it was steerable and used suction or vacuum assistance. Also record stone size, fragmentation method, laser use and complications, because the facility's claim and its ability to keep the payment rest on the physician's note.
• The physician reports 52353 or 52356, not an extra code, and the HOPD also reports C1747 at zero payment. Earlier advice to add a code for the two-catheter CVAC workflow is retired; use modifier 22 when extra time is documented, and Medicare wants the bundled C1747 disposable ureteroscope reported in the HOPD for cost tracking while the ASC bills C9761 alone.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 286, recorded April 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

New guidance on C9761 and the companies working with PRS

[00:00] Scott Painter: On this episode, new information on C9761. Stay tuned. Welcome to episode 286 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. On today's episode we have some new guidance that has come out in the last few weeks on C9761, for those of you who are not up to speed on everything. First, before we get started, Mark and Ray, I want to talk about the companies we're working with on our PRS Coding and Reimbursement Hub in regard to this subject. We've been working with Calyxo, Karl Storz and Dornier, and we really appreciate the leadership of those three companies. With all the confusion in the marketplace, the leadership and the teams there have all been very committed to working with us to get the right information out, because our ultimate goal is to get this new or emerging technology, and I know it's been out for several years or more in some cases, into the hands of the urology practitioner and make sure the patients are getting the most benefit from the tools that urologists and other QPs want to use. So Mark, I know you've had many conversations, a lot in the last couple of weeks, with those leadership teams. Do you want to comment on that?

[02:04] Mark Painter: Yeah. First of all, Scott, let's read the definition of C9761 so we know what everybody's talking about. It is called a new technology APC, and it is a procedure-based APC. For those of you who don't know, an APC is an ambulatory payment classification, and it is the method, or the grouper, that CMS uses to pay the ambulatory surgical center and the HOPD. They don't pay them at the same rate; there are formulas for each one as to how they're paid, but the baseline is essentially that an APC is the CPT of the outpatient payment world. They assign multiple CPT codes to each APC. A new tech APC is far more specialized, and it accommodates more expensive equipment for particular CPT codes or procedures. That's where we're starting from. So let's hear the C9761, Scott.

[03:21] Scott: Okay. C9761 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 applicable, and must use a steerable ureteral catheter.

[03:49] Mark: Thanks.

[03:50] Scott: I can also share the payments for C9761. The ASC payment is $6,612.45. The HOPD payment is $9,671.50. I'll compare that with the APC for CPT codes 52353 and 52356. 52353 is cystourethroscopy with ureteroscopy and/or pyeloscopy with lithotripsy, and in parentheses, ureteral catheterization is included. 52356 is cystourethroscopy with ureteroscopy and/or pyeloscopy with lithotripsy, including insertion of indwelling ureteral stent, e.g., Gibbons or double-J type. Those have a payment in the ASC of $2,729.66, and in the HOPD $5,477.93. So that's the lay of the land of what we're looking at.

What "must use a steerable ureteral catheter" means, and why documentation matters

[05:09] Mark: Yeah. And as you noted, even though the physician is paid differently for 52353 versus 52356, because there's a little extra work effort for the physician's insertion of the stent versus the lithotripsy without the stent, there is not a difference in how the HOPD or the ASC is paid. That gives you a window into how the APC groupers work. So, a little background there.

When we look back at C9761, the issue overall really focuses on the parenthetical of "must use a steerable ureteral catheter." The consideration is how the payer is going to interpret that parenthetical. As we look at every one of the IFUs, which are the instructions for use approved by the FDA for each of these devices, we need to look at how they've used that terminology. We've had arguments come in from different groups trying to define a sheath as a catheter, trying to define a scope with a camera as a catheter. Those discussions have really gone back to what is the definition of a catheter. If you look at Webster's dictionary, the definition leaves it wide open to interpretation; it's essentially a tube that carries fluid, which could fit any of those things. That's been the argument across the board. But we also know that traditionally, if you told a physician or a nurse this patient needs a catheter, they're not going to grab a sheath. They're going to grab what we traditionally think of as a catheter, like a Foley or a red rubber catheter. They're not going to grab a scope. That's a scope. This is at the base of all the discussions we've been having, and it's been difficult, because we're trying to predict, for now and for the future, what the payer interpretation is going to be and what they are going to pay for.

The other thing you should know, and this is part of the overall issue, is that C9761, based on its description from an ICD-10 and a CPT side of the equation, is going to look for whether the patient had, from a physician, the diagnosis of a ureteral or renal stone, and ultimately whether a 52353 or a 52356 was reported to the payer. Did they have lithotripsy through an endoscope performed on that patient? That's the map. So if C9761 goes in for a patient and that code combination was submitted by the physician, C9761 looks good, and the payer could process it and pay it based on just that information. The issue is whether the payer goes back and looks at the documentation. That's where the physician's documentation makes a huge difference.

So we're going to start again with the physician on all of this. Because there's this potential for interpretation on the payer side, what we're going to recommend is that as the physician, you document clearly what device you used. You want to make sure you mention that it was steerable, and that there was suction or vacuum assistance involved. And then of course you want to document carefully, as we've always told you, the size of the stone, how it was fragmented, whether you used the laser, whether there were any complications, all the clinical detail. Then you want to note that suction or vacuum assistance was used to clear the field, and finally that the device was steerable. All of that needs to be in the physician's note, because the physician's note is used to justify how the facility bills the claim, and to a second degree, how the facility is going to be paid for the claim, as well as whether they're going to be able to keep that payment based on the final interpretation of that payer.

The AHA Coding Clinic answers on sheaths and the CVAC system

Over the last week and a half, two weeks, we've received different information from different entities that are part of the payment process. The AHA, the American Hospital Association, is looked to as the authority from the professional side in the interpretation of HCPCS codes. Now, HCPCS codes are developed by CMS, and CMS has the ultimate authority over what new codes go into HCPCS and what they say. Applications can be made straight to the HCPCS committee, and that committee makes the decision. That body of individuals is not directly tied to reimbursement; that is a different group within CMS. So the coding committee makes the decision. We've been trying to get clarification, and not just we, but various manufacturers, on what they meant by "must use a steerable catheter," and we have not gotten an answer directly from CMS. So people went to the second-best source they knew, and that was the AHA. They asked three different questions of the AHA, and the AHA recently published, in its first-quarter Coding Clinic, three scenarios and their recommendations.

One of the questions asked about the use of a navigable access sheath. The AHA's answer was that it would be inappropriate to use C9761 because not all the components of the code are met, as a steerable catheter is not the same as a navigable access sheath. So the navigable access sheath is not a steerable ureteral catheter; that was the answer.

The second scenario asked specifically about the CVAC system. The answer came back that C9761 was indeed the right code to report when a CVAC system was used, because all of the components of C9761 were met, and this is a quote, "including cystourethroscopy, lithotripsy, use of a steerable ureteroscope, pyelogram, and ureteral stent placement." That was their answer for the CVAC system.

The last question was focused on a steerable suction ureteral access sheath. The AHA came back and said it would be inappropriate to report C9761 because the components are not met; a sheath is not considered a steerable ureteral catheter. So that was the advice from the AHA, which again is a leading authority from the professional side on how to interpret codes.

The AMA opinion and the MAC's position on ClearPetra

The second piece of information we got came from the AMA, another leading authority providing professional interpretation of codes. Now, the AMA has essentially no direct input into the development of HCPCS codes. CMS does have a seat on the AHA Coding Clinic. But we also know the AMA works with CMS on all of the CPT codes and the values that are assigned. There is a relationship between the AMA and CMS, and CMS has a seat within the CPT Editorial Panel, although it's one seat of many. In the end, their presence is felt in both entities. The AMA was asked a question by an individual, and the specific ask was: is a vacuum-assisted ureteral access sheath the same as a vacuum aspiration steerable ureteral catheter? The AMA's response was essentially that neither an access sheath nor a ureteroscope with a vacuum fits the definition of a steerable ureteral catheter with suction assistance. So the AMA's opinion was, if it's not labeled a steerable ureteral catheter, then it's not a catheter. That's not yet been published, but that is essentially the opinion the AMA has at this point in time, that we've seen in print.

The last piece of information goes back to where we started, to some degree: the payers are the ones who interpret these codes for their contracts and determine the coverage and payment levels. They may base things on Medicare guidelines, but in general they make decisions based on the codes and their contracts as to what they're going to pay and what's going to be included. One of the manufacturers, Karl Storz, went to the MAC medical directors and laid out what is included in the use of their device, the ClearPetra, and verbally the MAC directors said, yeah, it sounds like it should fit under C9761. They summarized that entire conversation and ran a document by Noridian, which is a MAC in the western part of the United States, that included a statement that the procedure they described with the ClearPetra met the qualifications for use of C9761, which would indicate that their policy is to pay C9761. However, what we have not yet seen from that MAC is a publication clearly stating that the sheaths would fit under C9761. We did see a very clear publication on Noridian's website that emphasized that, number one, CPT and HCPCS codes are not intended to be product specific, and in fact the MAC and CMS have the final say as to what will be covered under each of these codes and how they will be adjudicated, meaning under what circumstances they'll pay for them. We see that in payer bulletins and LCAs and LCDs all over the place.

Boiling it down: CVAC, steerable suction scopes and sheaths

When we take all of this information and boil it down, what we end up with is, number one, the physician really needs to be careful in their documentation to include the devices they use. Number two, they need to make sure their overall documentation has everything related to the surgery, both the clinical detail and the types of devices used. But when we come down to the interpretation side, we need to remember the final authority rests with the payer.

Right now, I would say, given the answers from the AHA and the information that is out there, the CVAC device clearly fits the definition of C9761. Scott and I went back and looked at the IFU, and the device is actually labeled as a steerable ureteral catheter, with ureteroscopy. When we look at all the labeling, that is why it fits the definition. The current payment for C9761 was actually based on information that looked at the CVAC as part of it. So if a payer is paying C9761 at this point in time, I think we can assume that the CVAC qualifies if you use that device. There are some other codes, like C1747, which is for a disposable ureteroscope, that may be allowed by some payers. Medicare considers it bundled but does require that the hospital report it, even though it will be paid zero; they want it reported in addition to C9761 in the HOPD setting for the purpose of tracking costs. So you want to bill both in the HOPD, but the ASC is just required to bill C9761.

For the steerable ureteroscope with suction capabilities, given what was said by the AHA, I think there is a little more support. But again, this is subject to interpretation by the payer, so we're going to recommend that if you use C9761, you would be very smart to check with the payer and make sure they consider a steerable ureteroscope with suction a payable service. We looked at a couple of IFUs, and essentially they're labeled as steerable ureteral endoscopes that function as steerable catheters. So there's some association there. There's some risk if you don't know what the payer's going to interpret, but you may have a more defensible position. There's risk, but there's no opinion other than the AMA's that is very specific against the steerable suction-assisted scope. Again, we'd recommend strongly that you check with your payer to make sure they understand what's being billed and they're going to allow you to keep your revenue for that.

For the sheath, we've got two opinions from bodies that are very influential stating that a sheath is not a steerable ureteral catheter. Again, the payer has the final authority as to whether they're going to allow that under C9761. So we're going to recommend that you check with your payer to see if they will allow the sheath procedure to be reported under C9761. Any time we say check with the payer, what you want to have is either a written policy that says they will pay for those, a contract with the payer that says it will pay specifically for those, or a conversation with the payer where you were able to obtain written confirmation that those devices are payable under C9761.

[23:33] Scott: Well said, very thorough. I think you did a nice job. Ray, any questions?

Dr. Ray Painter: No, I think that was very clearly stated. To cut it down to the two specific things a practice should do: one, the doc has to have the correct documentation, and number two, the payer has the last word, and it's up in the air as to how they're going to interpret some of these technologies. So they need to know for sure, and in all of these there's a certain amount of risk. All of the recommendations you make, the AMA, the AHA, et cetera, are well worth listening to, but the payer has the last say.

Outdated advice, sales reps, and the physician's coding

[24:36] Mark: Well stated and very true. As much as I'd like to say I'm an authority, as you know, I'm an opinion authority. We do our research with all of this. The last thing I'll add is that this process has been evolving over the last few years. The original device that came out in this space was the first version of CVAC, and it required two different catheters. So there was confusion in the very beginning about how the physician should report the service, because there was a lot of extra work changing out from one scope to another and navigating everything. There were recommendations from us, as well as the manufacturer, that you could report an additional code with all these new devices. That advice has expired and needs to be rejected at this point in time. Things have changed, as we've seen across the board. Ultimately, the physician is reporting lithotripsy of the stone with vacuum assistance under 52353 and 52356; whether or not you put in the stent is the difference when you're using a laser and suction assistance. If it takes a lot of extra time and the documentation supports it, you have the option of modifier 22. But that extra code from the beginning is older advice. It's out there on the web, and stuff doesn't get retired on the web the way it should, but that confuses things.

The other piece I'll throw out is that the sales representatives for a lot of these companies are having the same struggles. Everybody is trying to figure out the best way to sell the product they represent, and some of these sales reps are pretty strong in what they're pushing. I respect that their job is to sell their particular device. But we need to remember that we go through all this information and try to provide it to you in a method you can digest, and understanding what that allows or doesn't allow moving forward is going to affect your facility, either the HOPD or the ASC you work with. So keep all of that in mind. Hopefully everybody will get to the right messaging and it will give you the right information. But some of it is old information, people don't catch on as quickly, and this is a moving environment, as it always is in reimbursement.

[27:41] Scott: One last thing, Mark. I think the final thoughts jumped the gun there.

[27:47] Mark: Oh, yeah.

[27:47] Scott: I think we got the final thoughts, but I did ask you in the very beginning to comment on working with the various companies and their leadership, Dornier, Calyxo and Karl Storz. I wanted you to comment on that really quickly.

[28:06] Mark: Yeah. I will say that each one of them has definitely been amenable to working with us and dealing with where our position falls in this interpretation. They weren't always happy with what we came up with, but they understood. They supported the importance of getting the right information out there, so it was great to work with them on the leadership side. They understood that ultimately their clients are the most important part of any sale, and that they want to provide the right information. They backed this process as we've navigated through trying to give a reasonable pathway through these different positions and this confusion. So I did appreciate working with all of them.

Sponsor, hub resources and closing

[29:10] Scott: Very good. 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. The final thing I will say is that all these resources are now up on the PRS Urology Coding and Reimbursement Hub. You can go to prsnetwork.com/urologyhub to access this information. Included are pages for each of the devices we discussed: the CVAC system, the Dornier device, and the ClearPetra from Karl Storz. In addition, we have CodeMatrix guides for each of those products. I want to make sure you go check that out. We're going to be sending out emails letting you know how to access this information, but if you go to that site, you can easily see where all those tools are available. Ray, I'm going to give you a final comment.

[30:21] Ray: Stay up to date. Things are changing. Yes, they will. That's what we've been saying for the last 30 years.

[30:34] Scott: So true. And we will keep those pages up to date, so keep checking back. We do have a kidney stone page that has all the information Mark laid out today, so we encourage you to check that out on the PRS Coding and Reimbursement Hub at prsnetwork.com/urologyhub. Anything final to add, Mark?

[31:00] Mark: I think I've already added my adds, so we can leave it there for now.

[31:05] Scott: All right. That's all we have for today. Thank you all for listening, and thank you to the companies we've been working with on this particular project and this issue. Really appreciate that. All right, Ray, take us out.

[31:24] Ray: Happy coding.

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