Key takeaways from this episode

• CMS is revising the C9761 descriptor and adding a new code, C8014, expected effective July 1. Revised C9761 covers ureteroscopy with lithotripsy and steerable vacuum aspiration "with use of steerable ureteral catheter or suction-integrated ureteroscope"; new C8014 covers ureteroscopy with lithotripsy "including use of a suction-enabled ureteral access sheath with irrigation if performed," so sheaths are split from scopes.
• Preliminary 2027 APC data keeps C9761 in urology APC level six; C8014's placement is not yet published. PRS expects C8014 to land no lower than level five, where 52356 and 52353 sit, but will not speculate on five versus six until CMS releases the data.
• The physician's operative report drives the facility's coding and payment for these devices. Document exactly which scope, sheath or catheter was used; the urologist has no direct payment stake but is the one who documents and often chooses the equipment.
• Office procedures denied as "invalid place of service" can be appealed unless the code is a true inpatient-only or ASC-list procedure. Argue medical necessity and the office's ability to provide the service safely (for example with conscious sedation), but expect to lose on the true hospital-only codes.
• Even a winning appeal pays only the facility rate when the non-facility practice expense is N/A or equal to the facility value. Medicare will not pay for the disposables or equipment in the office for those codes, so do a financial double take before bringing them in; Mark cited Bulkamid as one example where the math does not work.
• To spot a "hospital-only" code, check whether the non-facility and facility totals in the Medicare fee schedule (or Coding Today) are identical. Many systems display the facility value in place of the N/A, so identical totals mean there is no office practice expense differential.
• An intraoperative consult supports an E/M only when another physician requests an opinion and the urologist documents history (from the record), a limited exam, and MDM with a recommended plan. If the urologist is called in to fix a problem, such as repairing a ureter cut by the OB-GYN, that is a procedure only and no E/M is billable; confirm consents were signed before the patient entered the OR.
• Do not code from old habits; CMS is auditing more through RACs, internal auditors and record requests. Mark's example: sacral neuromodulation codes 64561 and 64581 changed in 2022 to distinguish percutaneous from cutdown placement, and a group still using the old logic was caught in a dispute.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 291, recorded June 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

CMS revises C9761 and adds a new code for suction sheaths

[00:00] Scott Painter: On this episode: new developments with C9761, intraoperative consultations, and place of service restrictions. Stay tuned. Welcome to episode 291 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. We've had some new developments in the C9761 saga. It continues, and we wanted to bring you the information we have. We saw some new data posted and some new information, so we wanted to get that out to you. We don't have the complete story yet, but Mark, what's next in this chapter?

[00:46] Mark Painter: I think we can definitely call it a chapter in the book that continues to be the evolving use of suction, in addition to or for treatment of stones with scopes and sheaths. Many of you have heard this by now because it has spread fairly quickly. CMS indicated that they are going to add a new HCPCS code and revise the description of C9761.

To bring you those two changes first: C9761, as of July 1 we assume, will read "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 necessary, with use of steerable ureteral catheter or suction-integrated ureteroscope." They have removed the parenthetical referencing the steerable ureteral catheter and replaced it with a non-parenthetical phrase: "with use of steerable ureteral catheter or suction-integrated ureteroscope." So essentially it looks like CMS is trying to provide some guidance as to what should be reported with C9761, focusing on the information that came to us from the AHA Coding Clinic. Reading this, we would think your integrated suction scopes and your steerable ureteral catheters fall into C9761.

To supplement that, they have added a new code, C8014, which reads "cystourethroscopy with ureteroscopy and/or pyeloscopy with lithotripsy, including use of a suction-enabled ureteral access sheath with irrigation if performed." So they're coming down on the side of splitting sheaths from the scopes. As we look at those descriptions, that looks like the intention.

We'll start to see a couple of things as those are released, and one we're anxiously awaiting is where those will fall in the APC levels. The APC level is what's going to determine the reimbursement for each of those codes. At this point in time it looks like C9761 will stay in APC level six, so it will stay at its current reimbursement. We're looking at preliminary data. I was looking at a release of the preliminary data that's going to be used for the APC calculations for calendar year 2027, and C9761 continues to be referenced in the level six urology APC, which is where it is right now.

What we don't have a clue on yet is where the new C8014 is going to be placed. We're hoping that information drops in the next few days. We didn't see it as of this morning, but they are a month away from the July 1 launch of all of this, so we would assume it would come out today or early next week if they're following general timelines. But as we've seen this year, CMS has been a bit slower to release information than in the past, so we'll have to keep an eye on that one, and we'll let you know as we get the information whether it's going to fall into the level five or level six APC. We're assuming it won't be below level five. That's a fairly safe assumption, that they won't go below 52356 or 52353, which are both in level five. But we don't know if they'll put it in level six. We've got speculation, but we'll hold that, because we'd only be speculating for a week.

Why the facility codes matter to the urologist

[05:52] Scott: Yep. It's interesting as we talk through this. We understand that this issue is very important for the facilities, the ASCs and the HOPDs, and less important for the urologists who don't have a stake in those entities. It's interesting that it's such a wide topic, because a lot of urologists out there don't have a stake in an ASC or an HOPD, yet it's such an important decision for those facilities that it does involve the urologist making decisions or recommendations on the equipment they want to use in the stone procedure. It's a fascinating topic, and this is the next evolution of it. Hopefully it will bring some clarity so we don't have to talk about it as much. Ray, comments or questions?

[06:58] Dr. Ray Painter: No, nothing to add.

[07:00] Mark: Scott, I'll add that maybe the couching of the stakes, if you will, is that the physician has an indirect financial stake in the device reimbursement, because it is not a direct hit to their wallet one way or another. But there is no doubt that the facilities physicians work with make decisions in different ways. Some are very focused on the physician and what the physician needs. Others are so focused on the financial side that they may block physicians from devices they feel are better for patient treatment and care. So for some physicians it does affect them fairly directly, and that argument is paramount in those situations. That is one of those areas where they really have to understand the reimbursement picture as they discuss what equipment they get to use or don't get to use in the treatment of their patients. So you're right, it's absolutely not the financial issue directly impacting them, and that's important to point out. But I think one of the reasons the interest is there beyond the urologists in the ASC is those folks who are affected by the choices they can or cannot make because of the financial impact to the facility.

[08:55] Scott: That's so true, and having this information going into those discussions is really important, just knowing what the urologist wants out of the situation. Information is truly power, right?

[09:10] Mark: Yes, always. And again, in each case the documentation on the physician side of what device or equipment is used in the treatment of their patients is going to be paramount to how the facility is going to bill and code and, importantly, how they're going to get reimbursed. There is an integral link in all that we do, in or out of the office.

[09:43] Scott: Yep. Ray, anything more to add?

[09:47] Ray: I'd just add that it's another example that documentation is extremely important. Your operative report telling exactly what you did is what allows them to get paid for what they do when you are doing a procedure in a facility.

Place of service denials and the practice expense problem

[10:17] Scott: All right, let's move on to the next topic. We had a question come in from Teresa. Teresa asks, "Can I bill—"

[10:25] Mark: Hey, Scott, before you jump in, since we just had the facility discussion, let's do the other question first and then come back to this one. I think it's a better lead.

[10:36] Scott: Okay. Let's jump into the first question we have. Naisha asks, "My provider at times does these procedures in office since he has the ability to do so. I've had insurances deny them as invalid place of service. Can this be appealed, or are there procedures that should not be done in the office?" Another facility twist in all this. Mark, do you want to chime in on that?

[11:12] Mark: Yeah. This is one of those areas that is interesting in the way the payment structure is set up, and again, so much of what we do is not just about the clinical but also about the financial. We have a number of procedures within the CPT coding structure to which CMS, through the RBRVS, has assigned three values. Actually, we should say four values: the work value; the two practice expense values, the non-facility practice expense value, which is office-based, and the facility practice expense value, which is of course an HOPD, ASC or any group that has the ability to also charge for the equipment and personnel; and then the malpractice value. We never really talk much about the malpractice value, and we won't today, because it's a small piece of this and doesn't affect us as much. The ones we want to focus on in this case are the two practice expense values.

Essentially, the data set that comes into Medicare has an assignment of disposables and all of the equipment, and that is the differentiator between the non-facility practice expense value and the facility practice expense value. As we've preached for years, Medicare doesn't want to pay for anything twice, so that's one of the areas where they've set up the fee schedule to block that to a certain degree. Some of our CPT codes have the practice expense facility value assigned by Medicare as N/A or the same as the non-facility value. And then we have some procedures that have an N/A assigned to the facility value, because they're never paid in the facility. Most of those are radiology services, because radiology services and the technical components are bundled within the facility case in most instances. So the 26 will have a work value and a practice expense value, but essentially it's the same as the non-facility practice expense, because the technical component has all of that assigned.

But there are some office procedures in which the office-based practice expense is N/A, not applicable. Those are essentially considered hospital-only codes under the Medicare fee schedule. There are some payers that follow that and deny payment for procedures performed in the office based on the fact that there isn't a differentiated payment in the office setting. That's obvious for a lot of our larger procedures that are never performed in the office. But it does happen with some of our smaller procedures, as technology has advanced and offices have advanced to be able to provide conscious sedation or some of these slightly more advanced procedures that don't require a full OR. In those cases we see denials as an inappropriate place of service, or the place of service is not allowed.

We can appeal some of those. There are others that are on what used to be called the inpatient-only list that we're never going to win on appeal; those are difficult to support as done in a non-operating-room setting. But these in-between procedures are definitely areas where you can run an appeal. You can push the medical necessity, argue the ability of your office and your office setup to provide these services appropriately, and that they were medically necessary.

The other piece you need to consider is the financial piece. You are not going to be paid in the office setting, even if you win, an amount that would cover the disposables and the equipment. It's going to pay you the same whether you do it in the office, in an ASC or in a hospital. That's the end game even if you win the appeal. So financially, I would do a double take on procedures that have an equivalent practice expense value for facility and non-facility.

We're hoping one day, and this is one of my big beefs in all of this, that we get some site-of-service equivalence. There's not a great reason to have such a differential in payment between the office, the ASC and the hospital. Part of it is lobbying and part of it is the overall cost structure of a hospital versus an ASC. But there's less of an argument, in my opinion, for a differential between the ASC and the office. The equipment is the equipment, the support is the support, but the system just isn't designed that way. We've seen this become a bigger problem as more technology has evolved to allow us to perform procedures in the office. It's a difficult thing to swallow, and the overall system really is paying more because of this financial barrier to bringing things into the office. We know now that there are about 700 procedures that could be performed in the office and have a practice expense value for the office setting, but because of the conversion factor and the calculation of the practice expense, they actually pay less than the disposable required to provide the procedure. So you just can't do it in the office, and that's just dumb.

We know this in urology. I'll give one example: Bulkamid, the bulking of the sphincter around the urethra. That really is a procedure that could be done in the office, but financially it just doesn't make sense. You would think CMS would actually make this work, but it just hasn't happened, and hopefully someday it will. It gets under my skin. It's one of those things you have to watch for. So the answer would be: yes, you can appeal it; yes, you may win; but yes, you still lose on the financial side.

[19:22] Scott: You do not disappoint, because every time we talk about practice expense I hope you'll get on your soapbox. Even though we didn't talk about this in preparation, I knew the soapbox would come out.

[19:38] Mark: It's hard to let things go.

When the facility and non-facility values are the same

[19:42] Scott: Ray, comments, questions?

[19:45] Ray: I just enjoyed his explanation of where they were thinking.

[19:50] Mark: You mean not thinking. But yes, thank you.

[19:54] Scott: One clarifying question. Let's say the procedure is not on the inpatient-only list. The facility practice expense and the non-facility practice expense are the same. You do it in the office. You're saying you're not going to receive that non-facility practice expense payment?

[20:17] Mark: I am. And by the way, the other thing I'll mention is that the inpatient-only list is being phased out, but there's a second list, the approved ASC list, that is still behind the inpatient-only list in being phased out. So there are multiple ways CMS controls where they pay for things. But you're right: there is no differential. There is no practice expense for the non-facility setting that accommodates the disposables in those circumstances where an N/A was assigned to the non-facility practice expense. In essence, you're not getting any different reimbursement, which would be the amount that should be equivalent to paying for the disposables and the equipment used to provide the service.

[21:20] Scott: So if there is a non-facility practice expense value assigned, not an N/A, but the value is the same as the facility value, that is basically an N/A, is what you're saying.

[21:43] Mark: It is an N/A. In Coding Today, we often don't put the N/A in that calculation, because it would come up with a zero. To make it easier for folks to read through the Coding Today site, what you're looking for is whether the non-facility and the facility totals are the same. That's what a lot of folks do, because N/As mess up the processing on the computer and display side. So that's a good question, Scott. As you look through this, a lot of your programs will serve up a fee for the non-facility side that is equal to what you're paid for the facility, and that's really the way to consider it: as no differential, or an N/A, on the office side.

[22:52] Scott: And that's the data that comes out of CMS as well.

[22:56] Mark: Correct.

[22:57] Scott: In the Medicare fee schedule, it has identical values, so that's how they do it as well.

[23:03] Mark: Some of them do, and some of them assign the N/A. They're all over the board. As you know, dealing with this data coming through, there's a lot of normalization that has to be done.

Billing an intraoperative consultation

[23:15] Scott: Indeed. All right, let's move on to the final one. I know we're up against time, so we want to make sure we cover this, but let's do it efficiently.

[23:28] Mark: I'll try to be brief.

[23:32] Scott: Hopefully there's not as big a soapbox here. "Can I bill for the intraoperative consultation and procedure?" is the question Teresa asks. She says, "The description of the procedure and the consultation are provided only under the consultation note. In what situation can I bill for the intraoperative consultation and the procedure if the patient is under general anesthesia?"

[24:02] Mark: We used to have this conversation more frequently when we had coverage for the inpatient consultation codes, or consultation codes in general, and that waned a little over time. But the answer remains the same: it depends. It depends on how that call was made, and it depends on the documentation. I think the answer our team posted on the PRS community is very good. Essentially, if the physician is called into the operating room to provide their opinion, and that request was made by another physician, fitting the definition of a consultation, and the physician documents that they went into the operating room and evaluated the patient. Yes, the patient was under anesthesia, so they got the history from the note, and the physical exam was limited to what they could see. They then document that they provided medical decision-making: they evaluated the problem, whether they looked at any data, and they recommended a plan of care. Those are all things that fit into MDM.

The one piece that's probably missing is the shared decision-making, because the patient was under anesthesia. That is one of the things that's important in the overall medical process, so we want to make sure you've got the appropriate consents signed prior to the patient coming into the operating room. But that would allow for an inpatient consultation or inpatient code, or if they're outpatient, the outpatient code, which of course are the same right now. So it's possible to bill that E/M.

On the other side of the coin, let's say the OB-GYN nicked or cut the ureter doing a procedure, and the urologist was called in to repair the ureter. In that circumstance there's really not a request for a consultation; there's a request for a procedure. The urologist goes in and does what they are asked. That does not support an E/M. That is a procedure only. That's why it depends: on how or why the physician is called in, and then how they document the entire encounter, whether they had medical decision-making before they jumped in, or they scrubbed in and fixed something, which wouldn't allow for the consultation.

[27:16] Scott: Ray, comments, questions?

[27:19] Ray: Good answer. I don't have anything to add.

Sponsors, seminars and the hub

[27:22] Scott: Explained that well. All right, let's wrap this episode up. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, go to modmed.com/prsnetwork for specials for our listening audience. We also want to mention that registration for the Urology Advanced Coding and Reimbursement Seminar is open. Those are our seminars in December in Las Vegas and in New Orleans in January. We look forward to having a lot of these ongoing discussions, and there's a lot of new technology, including AI, that we'll be talking about: what works, what doesn't, all that good stuff. Go to prsnetwork.com, click the seminar registration button on the homepage, and get more information and pricing.

We also want to mention our hub, the PRS Coding and Reimbursement Hub. As Mark talked about at the very beginning, C9761: we have a lot of discussion up on our hub. Go to prsnetwork.com/urologyhub and check out the discussions on C9761 and kidney stones, as well as other technology and categories. We're adding to that constantly and building the hub up, so we encourage you to check it out. All right, let's get some final thoughts. Mark, final thoughts?

Final thoughts: stay current, and think of urology as a community

[28:56] Mark: I am currently getting ready to do a presentation at the Texas Urological Society. It's always fun to go around to the sections and the various state meetings. The reason I bring that up is that after this, I'll be changing my slides, which were required to be in a week ago, because now we have this update on the C code and everything that's going on. Always fun to deal with that, and always fun to go to the various state organizations and meet with the folks there.

In today's environment we are seeing so much change so quickly. I was reminded of this for a couple of reasons, and one was an argument we ended up having with a particular group that was based on old information, and that just doesn't work today. "I used to do it this way" doesn't mean you can keep doing it that way. You have to stay up to date. This particular argument was about sacral neuromodulation and the fact that for years we had 64561 for the temporary test stimulation and 64581 for the permanent. In 2022 that changed, and it became all based on whether you did a cutdown or did it percutaneously. That's the way the description is. Getting stuck in those ruts is an area CMS has gotten far more active in reviewing, through the RACs, through their internal auditors, which they're beefing up across the board, and ultimately through medical record requests. As with everything, a lot of it circles back to documentation, but it is also really important to stay on top of all of this. That's why we've been so involved in talking about C9761. We've dealt with things surrounding PCR and all of these different issues. They have to be revisited. It's not set it and forget it. It's an evolving marketplace, and you have to stay with the times.

We appreciate all of you listening to our podcasts and staying up to date, and we appreciate all the questions that come in that allow us to discuss this in greater detail and depth and make it more applicable to you. So keep sending us questions, keep being involved. The reality is it takes a community across the board. We are in the urology space trying to share information, because right now that adversarial relationship between the payer and the physician is unfortunately getting worse, and the patient is stuck in the middle. We, as physicians or as representatives of the patients through physicians, need to continue to make sure we're doing the right thing for the patient and continuing to push on the insurance companies, who seem less and less concerned with patients across the board.

[32:45] Scott: That's so true. As we mentioned when we were preparing for this, and you said it well, as far as competition between urologists in communities, there are enough patients in this country that there doesn't need to be that competition. The real competition, as you said, Mark, is the community of urologists and urology practices against the payers, in order to provide good care to the patients. That's an interesting place to be. Think of all the urology practices out there as a community helping each other and making the lives of patients better, because the more efficient and the better that care can be provided, the more helpful it is in the end. Ray, final thoughts?

[33:56] Ray: We've always said this system is not difficult, it's just complicated and constantly changing. As you may have seen over the years, PRS has changed with it, and it's good to see that Mark and Scott are creating that community, with communication not only with the physicians but with the payers, to get good information as it happens. This is exciting. Keep it up.

[34:38] Scott: All right. That's all we have for today. Thank you all for listening. Take us out, Ray.

[34:47] Ray: Happy coding and billing.

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