CPT 43262: ERCP with Sphincterotomy or Papillotomy
CPT code 43262 identifies an endoscopic retrograde cholangiopancreatography (ERCP) performed with a sphincterotomy and/or papillotomy — a combined diagnostic and therapeutic upper endoscopic procedure that injects contrast retrograde into the biliary ducts and incises the sphincter of Oddi or ampulla of Vater. Nationally, this code is used for care of patients with biliary or pancreatic duct obstructions, ductal stones, strictures, or select inflammatory and neoplastic conditions where both visualization and ductal access are required.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for CPT code 43262, common settings where the service is delivered, and what to expect in billing practice. The publication outlines reimbursement and utilization benchmarks when available, recent policy or coding guidance that affects ERCP and sphincterotomy coding, and operational considerations for documentation and claim submission. The summary supplies the essential coding narrative and points readers to areas where payers commonly apply medical necessity review or prior authorization for advanced endoscopic biliary procedures.
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Billing Code Overview
CPT code 43262 describes an endoscopic retrograde cholangiopancreatography (ERCP) with performance of a sphincterotomy and/or papillotomy. The procedure combines upper endoscopy with retrograde injection of contrast into the biliary ducts to visualize the biliary and pancreatic ductal systems and includes an incision of the sphincter of Oddi or the ampulla of Vater to open or enlarge the ductal outlet.
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Service type: Diagnostic and therapeutic endoscopic procedure (ERCP with sphincterotomy/papillotomy)
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Typical site of service: Hospital outpatient department or ambulatory surgery center; may also occur in endoscopy suites within acute care hospitals.
Clinical & Coding Specifications
Clinical Context
A 58-year-old patient presents with right upper quadrant abdominal pain, jaundice, and abnormal liver function tests suggestive of obstructive cholestasis. Noninvasive imaging (right upper quadrant ultrasound and/or MRCP) demonstrates a dilated common bile duct with suspicion for choledocholithiasis. The gastroenterology team schedules an endoscopic retrograde cholangiopancreatography (ERCP) with planned sphincterotomy for stone extraction. The patient is evaluated in the pre-procedure area, informed consent is obtained, and procedural sedation or monitored anesthesia care is arranged. In the endoscopy suite, an upper endoscope is advanced to the second portion of the duodenum, the ampulla of Vater is cannulated, contrast injected to opacify the biliary tree, and a sphincterotomy/papillotomy is performed to facilitate stone removal or biliary drainage. Post-procedure, the patient is observed in recovery for sedation-related effects and monitored for complications such as pancreatitis, bleeding, infection, or perforation before discharge or admission depending on findings and clinical status.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | When work, time, or complexity substantially exceeds usual for 43262. |
52 | Reduced services | When the procedure is partially reduced or not completed as documented. |
53 | Discontinued procedure | When the procedure is started but terminated due to extenuating circumstances. |
59 | Distinct procedural service | When another procedure performed at the same session is distinct and unrelated to the primary ERCP intervention. |
62 | Two surgeons | When two surgeons work together as primary surgeons during the procedure. |
66 | Surgical team | When a surgical team performs portions of the operative procedure. |
73 | Discontinued outpatient hospital/ambulatory surgery before anesthesia | When scheduled outpatient ERCP is discontinued prior to administration of anesthesia or sedation. |
74 | Discontinued outpatient after anesthesia | When ERCP is discontinued after anesthesia/sedation for reasons other than patient improvement. |
78 | Unplanned return to operating/procedure room by same physician following initial procedure for a related procedure during the postoperative period | When an unplanned repeat endoscopic procedure is required during the global period. |
79 | Unrelated procedure during the postoperative period | When an unrelated endoscopic or surgical procedure is performed during the global period. |
26 | Professional component | When billing only the physician’s interpretation/technical reading component is separated (rare for 43262). |
TC | Technical component | When billing only the facility/technical component of the service (facility-based billing scenarios). |
22 | Increased procedural services | Duplicate entry avoided; see first row for use. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207K00000X | Gastroenterology | Primary specialty that performs diagnostic and therapeutic ERCP including sphincterotomy and stone extraction. |
| 208000000X | General Surgery | Surgeons with advanced endoscopy training may perform ERCP in some settings. |
| 363L00000X | Anesthesiology | Provides monitored anesthesia care or general anesthesia for complex or high-risk ERCP cases. |
| 207RG0100X | Advanced Gastrointestinal Endoscopy | Subspecialty taxonomy for endoscopists focused on complex biliary and pancreatic procedures. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
K80.1 | Calculus of bile duct with cholangitis | Common indication for ERCP with sphincterotomy to remove obstructing bile duct stones and treat infection. |
K80.3 | Calculus of bile duct with acute cholecystitis | Stones in duct causing inflammation; ERCP may be used to clear duct prior to or after cholecystectomy. |
K83.0 | Cholangitis | Biliary infection requiring urgent ERCP for decompression and drainage. |
K83.1 | Obstruction of bile duct | ERCP used to identify and relieve obstruction via sphincterotomy, stone extraction, or stenting. |
K85.1 | Biliary acute pancreatitis | ERCP with sphincterotomy may be indicated in selected cases with persistent obstruction from gallstones. |
C24.0 | Malignant neoplasm of extrahepatic bile ducts | ERCP used for diagnosis, stent placement, or palliation in malignant biliary obstruction. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
43260 | Endoscopic retrograde cholangiopancreatography, diagnostic, with or without collection of specimen(s) by brushing or washing when performed (ERCP) | Diagnostic ERCP without sphincterotomy; may precede or be an alternative if no intervention is performed. |
43264 | Endoscopic retrograde cholangiopancreatography, with removal of stones, including dilation of ampulla when performed | Used when stone extraction is performed and may be reported with or instead of 43262 depending on documentation and payer rules. |
43265 | Endoscopic retrograde cholangiopancreatography; with stent placement in biliary or pancreatic duct(s) | Performed when biliary drainage via stent is required in addition to or instead of sphincterotomy. |
43267 | Endoscopic retrograde cholangiopancreatography; with removal of obstructing tumor or debulking procedures | Used for malignant obstruction management during ERCP sessions. |
43269 | Endoscopic retrograde cholangiopancreatography; with lithotripsy | Performed when stones require lithotripsy in addition to sphincterotomy for removal. |