Summary & Overview
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.
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. |