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CVAC System Reimbursement Insights

C9761, C8014, or 52353/52356? What Coders Need to Know About Suction-Assisted Lithotripsy for Kidney Stones

CMS has added new language to C9761, and AHA Coding Clinic reinforces the central coding question: What service was actually performed?

Endoscopic kidney stone procedures can look similar on the claim while involving different technologies, documentation, and payment pathways. That is why the choice among CPT® 52353¹, CPT® 52356², newly created HCPCS Level II C8014³, and HCPCS Level II C97614 deserves careful attention.

Payment Differential between C9761 and CPT 52353/52356 or C8014
Setting
Comparison
Difference
Setting
Hospital outpatient department
Comparison
C9761 vs. CPT 52353/52356 & C8014
Difference
+$4,505
Setting
Ambulatory surgery center
Comparison
C9761 vs. CPT 52353/52356
Difference
+$4,482
Setting
Ambulatory surgery center
Comparison
C9761 vs. C8014
Difference
+$3,499
Proposed CY 2027 Medicare national unadjusted payment rates.

As AAPC previously explained, the significant payment differential between C9761 and CPT 52353/56 and C9761 and C8014 increases the compliance risk when a facility reports C9761 without documentation clearly supporting the higher-level service. The financial stakes also mean that Medicare and commercial payers may scrutinize the operative report, device used, and work performed—not just the code selected.

See AAPC’s December 2025 article, “Kidney Stones: Breaking Down Endoscopic Lithotripsy.”

What changed in 2026?

Effective July 1, 2026, CMS created HCPCS Level II C8014 for lithotripsy performed with a suction-enabled ureteral access sheath. The new code gives facilities and CMS a separate claims identifier for this access-sheath treatment pathway and creates a clearer starting point for distinguishing it from the steerable vacuum-aspiration service described by C9761.
At the same time, CMS revised the C9761 long descriptor to add “or suction-integrated ureteroscope.” Previously, the coding discussion was often framed around a steerable ureteral catheter. The revised language recognizes two potential C9761 device pathways: a steerable ureteral catheter or a suction-integrated ureteroscope.

These two changes create confusion about whether every ureteroscope with a suction function supports C9761. In its August 31, 2026, comment letter on the CY 2027 OPPS/ASC proposed rule, Calyxo requested clarification and asked CMS to define “integrated” in functional, documentation-based terms and to distinguish C9761 from both the newly created C8014 pathway and the existing CPT 52353/52356 pathway.

Three practical coding pathways

In its comment letter, Calyxo suggested that CMS define and provide examples of the following pathways:

1. Standard ureteroscopy and lithotripsy: CPT 52353 or 52356

Use the standard pathway when the documentation supports ureteroscopy and lithotripsy but does not support the steerable vacuum-aspiration service described by C9761.

This can include a suction-capable ureteroscope used to:

  • Clear the visual field
  • Evacuate irrigation fluid
  • Remove fine dust or debris
Those functions, by themselves, do not establish C9761-level aspiration. The presence of a single-lumen direct in-scope suction, or DISS, ureteroscope should not automatically move the case into C9761. “Standard” describes the reporting pathway—not necessarily the physical design of the ureteroscope.

2. Suction-enabled access sheath: C8014

C8014 is the newly created pathway for lithotripsy performed with a suction-enabled ureteral access sheath when the sheath provides the procedure-defining evacuation. The ureteroscope used in this procedure may also have suction capability, but that fact alone does not change the pathway. If the ureteroscope’s suction is used only for field clearing, irrigation, or dust evacuation, the case remains in C8014 when the access sheath provides the defining suction service.
A useful coding question is: Which device performed the service that makes this procedure different from standard lithotripsy?

3. Steerable vacuum aspiration: C9761

C9761 should be reserved for cases in which the record supports the full descriptor, including:
  • Cystourethroscopy with ureteroscopy and/or pyeloscopy
  • Lithotripsy
  • Ureteral catheterization as described by the code
  • Actual steerable vacuum aspiration of the kidney or collecting system, or another anatomic site identified in the descriptor
  • Use of a qualifying device—a steerable ureteral catheter or a suction-integrated ureteroscope—that performed the aspiration
The important distinction is between a device predicate and a service predicate. A qualifying device may be present, but the documentation must also show that the device performed the described steerable vacuum aspiration.

What AHA Coding Clinic reinforces

AHA Coding Clinic for HCPCS, Third Quarter 2026, addresses the C9761 revision and reinforces a documentation-based distinction between device capability and the service actually performed. The publication explains that C8014 should be assigned when the documentation supports use of a suction-enabled ureteral access sheath, while C9761 requires documentation that the qualifying device performed the steerable vacuum aspiration.

This guidance comports with the clarifications Calyxo requested from CMS: a functional, documentation-based boundary between C8014 and C9761, rather than a code assignment based on device capability alone.

The AHA Coding Clinic article states:

“The documentation [for C9761] must support that the device [i.e., the steerable ureteral catheter or suction-integrated ureteroscope] was used to perform steerable vacuum aspiration of the kidney, collecting system, ureter, bladder, and/or urethra, as applicable, as described by the HCPCS Level II code descriptor.”

This guidance reinforces that the mere presence of a qualifying device is not sufficient; the record must show that the device itself performed the described aspiration. AHA Coding Clinic does not specifically address the DISS combined with a suction-enabled ureteral access sheath scenario. Applying the AHA documentation principle, however, if the suction-enabled ureteral access sheath performs the aspiration while DISS is used for visualization, lithotripsy, irrigation, or limited dust clearance, the procedure is more consistent with C8014 than C9761.

Documentation points for coders and auditors

The operative note should make the coding pathway clear. For a potential C9761 case, documentation should identify:

  • The device model and suction architecture
  • Whether the device was a steerable ureteral catheter or a suction-integrated ureteroscope
  • The target of aspiration, such as the kidney or collecting system
  • How and when steerable vacuum aspiration was performed
  • The role of any second suction device, including an access sheath
  • Whether irrigation, visualization, deflection, and instrument passage remained available when the device was used
C8014 cases should identify the suction-enabled access sheath and describe its role in the procedure. For standard cases, the record should not be interpreted as supporting C9761 merely because a suction-capable ureteroscope was available or used for limited evacuation functions.
As AAPC previously noted, ICD-10-CM does not provide a separate code for “complex calculi.” Coders therefore must rely on the operative documentation to understand the procedure performed and should query the provider when the device, aspiration method, or service distinction is unclear.
Product names and HCPCS device reporting, including broad device codes such as C1747⁵, should not substitute for documentation of the C9761 service.

Current status: AHA Coding Clinic reinforces a documentation-based approach

Calyxo’s current comment letter supports CMS’s creation of C8014 and asks CMS to clarify the boundary between C8014 and C9761. It recommends examples and sub-regulatory guidance that would separate:
  • Standard ureteroscopy and lithotripsy, including limited use of suction-capable ureteroscopes
  • C8014 procedures in which a suction-enabled access sheath provides the defining evacuation
  • C9761 procedures in which a qualifying catheter or suction-integrated ureteroscope performs steerable vacuum aspiration

AHA Coding Clinic’s Q3 2026 guidance strengthens this framework by stating that documentation must show the device performed the steerable vacuum aspiration described by C9761. It therefore reinforces the need to distinguish a qualifying C9761 service from limited suction functions or a case in which a suction-enabled access sheath provides the procedure-defining evacuation.

Bottom line for coders

When reviewing a stone procedure, start with the documented service, not the equipment label:
  • Do not assign C9761 solely because a ureteroscope has suction capability.
  • Do not assume that the presence of “suction” satisfies the “steerable vacuum aspiration” service requirement of C9761.
  • Use C8014 when a suction-enabled access sheath provides the procedure-defining evacuation.
  • Look for documentation that the qualifying device itself fully performed the aspiration service as described by C9761.
  • Query when the operative note does not identify the device, target, method, or role of each suction component.
Until CMS provides more detailed guidance, a careful, documentation-based approach is the best protection against miscoding, audits, recoupments, and distorted payment data. For coders, the practical rule is simple: code the work that was performed and documented—not the suction capability that happened to be available.

Footnotes: Code descriptors

  1. CPT® 52353: Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included).
  2. CPT® 52356: Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type).
  3. HCPCS Level II C8014: Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with lithotripsy, including use of a suction-enabled ureteral access sheath, with irrigation (if performed).
  4. HCPCS Level II C9761: 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.
  5. HCPCS Level II C1747: Endoscope, single-use (i.e., disposable), urinary tract, imaging/illumination device (insertable).

Sources

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