Summary & Overview
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.
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. |