Reporting use of ureter access sheath with suction component

We have recently started using a new flexible and navigable ureter access sheath with an integrated suction component that can aspirate small stone fragments created during ureteroscopy with laser lithotripsy. Would it be appropriate to report Current Procedural Terminology (CPT) code 52356 for the ureteroscopy with laser lithotripsy with stent placement, and also report CPT code 53899 (unlisted urological procedure, crosswalked to CPT code 52001 for cystoscopy with irrigation and evacuation of multiple obstructing clots) for the placement of the flexible aspirating sheath with stone evacuation? Also, can we use the same Healthcare Common Procedure Coding System (HCPCS) billing code (C9761) used for the fluoroscopic-guided suction stone evacuator?

Jonathan Rubenstein, MD

Thank you for this question. So, you are asking whether it is appropriate to report CPT code 53899 (crosswalked to 52001) for the additional work of placing ureter access with suction capabilities in addition to CPT 52356 for the situation described above. To best answer that question, we need to understand what is and is not already included when reporting CPT code 52356 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double J]) and what can be reported separately.CPT code 52356 includes all items typically performed during a ureteroscopy with laser lithotripsy and stent placement and other codes should not be reported separately even if they have a CPT code for when they are performed alone.This includes CPT codes such as cystoscopy (CPT 52000), cystoscopy with ureteral catheter placement (52005), diagnostic ureteroscopy (52351), ureteroscopy with laser lithotripsy (52353), and cystoscopy with stent placement (52332). The work and value of those codes is already included in CPT 52356. Other codes that may be reported if needed during a procedure, such as dilating the urethral meatus to access the urethra or dilating the ureter orifice to allow access to the ureter, would also be included and not separately reported. Extraction procedures for the treated stones, such as reportable with CPT code 52310 (cystoscopy with foreign body, calculus, or ureteral stent from urethra or bladder, simple (52310) or complex (52315), cystourethroscopy with removal of ureteral calculus (52320), and ureteroscopy with removal or manipulation of calculus (52352) are part of CPT code 52356 and not separately reported. (Please see the next question for additional discussion of what is included in the

Mark Painter

global period of any procedure.) Based upon the concept that ureter catheter placement and stone removal are included in the work of 52356, it is not clear that additional work performed, if any, appropriately supports using an additional code such as 53899. However, if the operative note for the procedure clearly describes additional time, work, and effort and the work is justified as medically necessary, modifier -22 may be supported. Modifier -22 is considered a request for additional reimbursement based on the work performed for that case. A manual review of the operative note by the payer is required in most cases. Additionally, we would recommend that a short description of the extra work performed and reflected in the documentation be added to box 19 of the claim to assist in proper processing by the payer.

HCPCS code C9761 describes 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 (must use a steerable ureteral catheter). This billing code can be used to report the expense of the additional equipment of a vacuum aspirator of residual kidney stone debris after lithotripsy by the facility (ambulatory surgical center [ASC] or hospital-based outpatient department [HOPD]). The code was effective on October 1, 2020; for calendar year 2023, Medicare assigned HCPCS code C9761 to Ambulatory Payment Classification 5376 (Level 6 Urology and Related Services). The code describes using a sterile, single-use, steerable ureteral aspiration-irrigation catheter designed to assist in removing stone fragments during a standard ureteroscopy. Like many others, this C code does not have a professional component and, as noted above, is specifically used to for facility reimbursement.

This code has come under some scrutiny. During its early use, there was a concern that some facilities reported HCPCS code C9761 for some ureteroscopic procedures despite not using a steerable vacuum aspiration catheter, likely because of the similarity between the long descriptors for HCPCS code C9761 and CPT code 52356.

In your question, you do not describe using a steerable vacuum aspiration catheter but instead refer to a ureteral access sheath with aspiration capabilities. The CPT and HCPCS codes must be used only to report those devices/services accurately reflected in the description. Based on your question, C9761 would not be appropriate for using the access sheath.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.