AHA Coding Clinic® for HCPCS - 2026 Issue 1; Ask the Editor

HCPCS Code C9761

A patient presents for removal of bladder stones and a ureteral stent exchange. A cystourethroscopy revealed no abnormalities, and the left stent was removed and cannulated with a guidewire. A 12/14 French flexible and navigable suction access sheath was inserted through the urethra and advanced into the ureteral orifice. A disposable ureteroscope was inserted through the flexible and navigable access sheath and advanced up to the level of the stone. The first stone was fragmented to approximately 1.5mm using the laser. The second stone was in a diverticulum. The neck of the diverticulum was dilated with the beak of the ureteroscope, and the stone was lasered in situ. The laser fiber was used as a fiducial for visual assessment of both fragmented stones to confirm completion of lithotripsy. The stone fragments were removed using continuous suction from the flexible and navigable access sheath.Left retrograde pyelogram (injection of contrast via ureteral catheter) showed no extravasation or stones. The guidewire was left in place, and the ureteral access sheath was removed. A temporary left stent was placed. For facility reporting, would the documentation support assigning HCPCS code C9761 for a cystourethroscopy, lithotripsy and pyelogram, performed with a flexible and navigable suction access sheath with a separate steerable ureteroscope? If not, what is the appropriate CPT or HCPCS code for the procedures performed based on the documentation? ...

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