Summary & Overview
CPT 43264: ERCP Upper Endoscopy with Ductal Contrast and Stone Removal
CPT code 43264 represents an endoscopic retrograde cholangiopancreatography (ERCP) procedure that combines diagnostic upper endoscopy, retrograde contrast injection into the biliary and pancreatic ducts with fluoroscopic imaging, and therapeutic removal of stones or debris from one or more ducts. This procedure is clinically important for diagnosing and treating obstructive biliary and pancreatic disorders, including choledocholithiasis and ductal debris, and has significant implications for acute care, surgical planning, and outpatient therapeutic workflows nationwide.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication summarizes payer coverage considerations, typical sites of service, and clinical context for use of CPT code 43264.
Readers will learn the clinical scope of the code, where the procedure is typically performed (hospital outpatient departments and ambulatory surgical centers), and the common clinical indications that drive utilization. The report also provides benchmark-oriented content on billing practices, notes on common modifiers where applicable, and contextual information to inform coding, claims submission, and administrative processes. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 43264 describes an endoscopic retrograde cholangiopancreatography (ERCP) procedure that combines diagnostic upper endoscopy with retrograde injection of contrast into the biliary and pancreatic ducts to obtain fluoroscopic imaging and remove stones or debris from one or more biliary/pancreatic ducts.
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Service type: Diagnostic and therapeutic endoscopic procedure combining upper endoscopy with contrast injection and fluoroscopic imaging for biliary and pancreatic duct evaluation and stone/debris removal.
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Typical site of service: Hospital outpatient department or ambulatory surgical center where endoscopy and fluoroscopy are available for ERCP and therapeutic ductal interventions.
Clinical & Coding Specifications
Clinical Context
A typical patient is a 58-year-old female presenting with right upper quadrant abdominal pain, jaundice, and abnormal liver function tests suggesting obstructive cholestasis. Noninvasive imaging (right upper quadrant ultrasound and/or MRCP) demonstrates a dilated common bile duct with suspected choledocholithiasis. The gastroenterology team schedules combined upper endoscopy with endoscopic retrograde cholangiopancreatography (ERCP) and stone extraction using biliary sphincterotomy and retrieval devices. The procedure is performed in an endoscopy suite or hybrid operating room under monitored anesthesia care or general anesthesia. The workflow includes pre-procedure consent and coagulation assessment, antibiotic prophylaxis when indicated, endoscopic cannulation of the ampulla, injection of contrast under fluoroscopy to visualize biliary and pancreatic ducts, removal of stones or debris from one or more ducts, placement of biliary stent if needed for drainage, post-procedure monitoring for pancreatitis, bleeding, perforation, or cholangitis, and documentation of findings and interventions in the procedural note. Typical payors include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When billing separately for physician interpretation when facility bills technical component |