CPT 43260: Diagnostic ERCP with Upper Endoscopy and Biliary Contrast
CPT code 43260 designates a combined upper endoscopy with retrograde injection of contrast into the biliary tree to produce fluoroscopic imaging of the bile ducts, gallbladder, and pancreas; specimens may be obtained by brushing or washing. This procedure is a core diagnostic tool in gastroenterology for evaluating biliary obstruction, cholangitis, and pancreaticobiliary neoplasia, with implications for downstream diagnostic and therapeutic planning.
Key payers included in this national overview are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for CPT code 43260, common sites of service, and the procedural purpose. The publication outlines what stakeholders typically examine when reviewing this code: billing and coding considerations, alignment with clinical indications, and service-site implications for reimbursement and utilization.
The report provides national-level benchmarks and policy-relevant updates where available, plus practical summaries of documentation elements tied to the code’s diagnostic intent. Data not available in the input is noted where applicable. This summary is intended to support coding professionals, clinicians, and policy analysts seeking a clear, single-page reference for CPT code 43260 and its role in pancreaticobiliary diagnostic workflows.
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Billing Code Overview
CPT code 43260 describes a diagnostic endoscopic procedure that combines upper endoscopy with retrograde injection of contrast into the biliary ducts to obtain fluoroscopic images of the gallbladder, pancreas, and bile ducts. The procedure may include collection of specimen(s) by brushing or washing for diagnostic analysis.
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Service type: Diagnostic endoscopic retrograde cholangiopancreatography with endoscopic visualization and contrast injection
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Typical site of service: Hospital outpatient department or ambulatory surgery center where combined endoscopy and fluoroscopy can be performed
Clinical & Coding Specifications
Clinical Context
A 56-year-old patient presents with progressive jaundice, right upper quadrant pain, and abnormal liver function tests; cross-sectional imaging suggests a possible choledocholithiasis or obstructing biliary stricture. After initial evaluation in the outpatient clinic and failed noninvasive management, the gastroenterologist schedules an endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic evaluation. In the endoscopy suite or hospital endoscopy unit, under moderate sedation or monitored anesthesia care, the provider performs upper endoscopy to access the ampulla, cannulates the biliary tree, injects contrast retrograde into the bile ducts under fluoroscopy to delineate the common bile duct, intrahepatic ducts, cystic duct and pancreatic duct as indicated, and may obtain brushings, washings, or ductal aspirates for cytology or culture. The typical workflow includes pre-procedure consent and assessment, NPO status, anesthetic plan, prophylactic antibiotics if indicated, performance of diagnostic cholangiography with sampling as needed, post-procedure monitoring for complications (bleeding, pancreatitis, infection, perforation), and discharge instructions or inpatient admission based on procedural findings and patient stability.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When billing only the physician’s interpretation/technical overlay is billed separately from facility/technical components. |
51 | Multiple procedures | When multiple unrelated procedures are performed at the same session and payer requires modifier for multiple procedures. |
52 | Reduced services | When the ERCP/diagnostic cholangiography is intentionally partially reduced or not completed as originally planned. |
53 | Discontinued procedure | When the procedure is started but terminated due to extenuating circumstances or safety concerns. |
59 | Distinct procedural service | When another procedure performed at the same session is distinct and separate from the ERCP diagnostic service. |
62 | Two surgeons | When two surgeons work together as primary surgeons during a complex therapeutic ERCP (rare). |
63 | Procedure performed on infants (<4 kg) | When applicable for very small pediatric patients; document weight. |
76 | Repeat procedure by same physician | When the same physician repeats the ERCP within the global period. |
77 | Repeat procedure by another physician | When a different physician repeats the ERCP within the global period. |
78 | Return to operating/procedure room for a related procedure during the postoperative/global period | When an unplanned return to procedure room is required for a related complication. |
79 | Unrelated procedure or service by the same physician during the global period | When an unrelated procedure is performed within the global period. |
52 | (duplicate) Reduced services | See above. |
59 | (duplicate) Distinct procedural service | See above. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207RC0000X | Gastroenterology | Most common specialty performing diagnostic and therapeutic ERCP. |
| 208000000X | General Surgery | Surgeons may perform ERCP in some settings or surgical endoscopy teams. |
| 207RH0000X | Interventional Gastroenterology | Subspecialists focused on advanced endoscopic biliary and pancreatic procedures. |
| 2084P0800X | Colon & Rectal Surgery | Less common but may be involved in complex periampullary surgical care. |
| 207K00000X | Surgery of the Hand | Data not available in the input. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
K80.1 | Calculus of gallbladder with other cholecystitis | Stones can migrate causing biliary obstruction visualized on ERCP. |
K80.3 | Calculus of bile duct | Direct indication for ERCP to image and remove common bile duct stones. |
K83.1 | Obstruction of bile duct | ERCP identifies level and cause of obstruction and allows sampling or intervention. |
K83.0 | Cholangitis | ERCP is used for diagnosis and drainage when infection with obstruction is present. |
K86.1 | Other chronic pancreatitis | Biliary imaging during ERCP can assess pancreatic ductal anatomy and secondary biliary issues. |
R17 | Unspecified jaundice | Diagnostic indication when hyperbilirubinemia suggests biliary obstruction. |
R10.11 | Right upper quadrant pain | Symptom prompting biliary imaging with ERCP to evaluate for stones or obstruction. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
43260 | Diagnostic endoscopic retrograde cholangiopancreatography with cholangiography; diagnostic, may include brushing or washing for analysis | Primary procedure: diagnostic ERCP with contrast injection into biliary ducts and possible specimen collection. |
43262 | Endoscopic retrograde cholangiopancreatography; with diagnostic cholangiography including sphincterotomy, stone removal, or stent placement (therapeutic) | Performed when diagnostic findings necessitate therapeutic intervention such as sphincterotomy, stone extraction, or stent insertion during the same session. |
43274 | Endoscopic retrograde cholangiopancreatography with removal of calculus(es) from biliary tract, with or without sphincterotomy | Used when choledocholithiasis is identified and stones are removed during the ERCP. |
43269 | Endoscopic retrograde cholangiopancreatography with insertion of biliary stent | Used when a biliary obstruction requires temporary or permanent stent placement following diagnostic imaging. |
43255 | Upper gastrointestinal endoscopy, diagnostic, flexible, transoral; with biopsy(s) | May be performed concurrently if mucosal biopsies of the ampulla or duodenum are required. |