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.
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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 |
52 | Reduced services | When the procedure is partially reduced or incomplete but not abandoned |
53 | Discontinued procedure | When the procedure is terminated due to extenuating circumstances prior to completion |
54 | Surgical care only | When another provider bills post-operative care separately |
55 | Postoperative management only | When another provider performed the procedure and current provider manages postop care |
59 | Distinct procedural service | To indicate a separate, distinct procedure or service on the same day |
62 | Two surgeons | When two surgeons work together as primary surgeons |
66 | Surgical team | For services furnished by a surgical team |
73 | Discontinued outpatient hospital/ambulatory surgery center prior to anesthesia | When canceled after patient arrival but before sedation/anesthesia |
91 | Repeat clinical diagnostic laboratory test | For repeat diagnostic testing related to procedure (lab repeat during same encounter) |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207K00000X | Gastroenterology | Physicians who commonly perform ERCP and biliary interventions |
| 208000000X | General Surgery | Surgeons who may perform related biliary endoscopic or operative procedures |
| 3336C0003X | Anesthesiology | Providers delivering monitored anesthesia care or general anesthesia for the procedure |
| 261QM0800X | Radiology, Diagnostic | Radiologists interpreting fluoroscopic imaging when separate interpretation is billed |
| 363LP0800X | Interventional Gastroenterology | Subspecialists focused on advanced endoscopic biliary procedures |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
K80.1 | Calculus of bile duct with cholangitis | Choledocholithiasis with ascending cholangitis commonly prompts ERCP with stone extraction |
K80.2 | Calculus of bile duct without cholangitis | Common bile duct stones causing obstruction; indication for diagnostic and therapeutic ERCP |
K83.1 | Obstruction of bile duct | Biliary obstruction from stones, strictures, or external compression identified and treated via ERCP |
K82.0 | Cholelithiasis with acute cholecystitis | Gallstone-related complications that coexist with biliary duct stones may necessitate ERCP |
K85.9 | Acute pancreatitis, unspecified | Post-ERCP pancreatitis is a known complication; ERCP is also used when pancreatitis is due to biliary obstruction |
K83.8 | Other specified diseases of biliary tract | Includes biliary leaks, strictures or other pathologies addressed during ERCP |
R17 | Unspecified jaundice | Jaundice from biliary obstruction often prompts biliary imaging and ERCP for diagnosis and therapy |
R10.11 | Right upper quadrant pain | Abdominal pain localizing to RUQ is a common presenting symptom leading to ERCP evaluation |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
43235 | Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum or jejunum; diagnostic, flexible, transoral | May be performed immediately prior to 43264 as the diagnostic upper endoscopic component or when diagnostic endoscopy alone is performed |
43267 | Endoscopic retrograde cholangiopancreatography, with endoscopic sphincterotomy, with or without dilation of the papilla; when performed with biliary stone extraction | Alternative/add-on code used when sphincterotomy with stone extraction is the primary biliary therapeutic maneuver |
43268 | Endoscopic retrograde cholangiopancreatography with insertion of stent into bile or pancreatic duct | Performed during the same session if stent placement is required for drainage after stone extraction or ductal injury |
43246 | Endoscopic retrograde cholangiopancreatography, diagnostic, with or without collection of specimens by brushing or washing | Used when diagnostic ERCP without therapeutic intervention is performed |
43188 | Endoscopic removal of lesion(s) of esophagus, stomach or duodenum; polypectomy, hot or cold snare | May be performed during the same endoscopic session if mucosal lesions requiring removal are encountered |