AHA Coding Clinic® for HCPCS - 2026 Quarter 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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Article Overview
This premium article focuses on a bladder and ureteral stone removal scenario and describes the procedural workflow used in an endoscopic urology case. It is relevant to coders, billing staff, and clinical documentation specialists who need to understand how the service is documented and how the associated HCPCS topic is framed. The content centers on the procedure narrative, device and access approach, and imaging performed during the encounter.
Why This Topic Matters
Understanding the documentation context for this HCPCS topic helps users evaluate whether the article applies to a similar urologic case and supports more accurate review of procedure notes involving stone treatment and ureteral access.
What You Will Learn
- The clinical and procedural context associated with the HCPCS topic
- How the endoscopic stone-removal case is documented
- What types of operative steps and imaging are discussed in the article
- How the article frames the relevant urology coding scenario
Who Should Read This
- Medical coders
- Coding auditors
- Billing specialists
- Clinical documentation improvement staff
- Urology practice staff
Codes Discussed
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