Summary & Overview
CPT 43265: ERCP with Pancreaticobiliary Evaluation and Stone Destruction
CPT code 43265 represents an endoscopic retrograde cholangiopancreatography (ERCP) procedure combining endoscopic inspection of the duodenum and papilla of Vater with radiologic evaluation of the pancreatic duct and biliary tree, and includes stone destruction by any method. This code captures a common therapeutic intervention for obstructive biliary and pancreatic conditions and is relevant for hospitals, ambulatory surgical centers, gastroenterology practices, and payers managing high-acuity procedural care.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a national perspective on coding and utilization patterns for ERCP with lithotripsy or other stone-destruction techniques.
Readers will learn the clinical context and typical sites of service for CPT code 43265, plus what to expect in payer coverage patterns, common billing modifiers, and related service-line considerations. The report summarizes benchmarks for utilization and reimbursement where available, highlights recent policy or coding clarifications affecting ERCP services, and outlines operational implications for scheduling, documentation, and facility requirements. Data not available in the input is noted explicitly where applicable.
Billing Code Overview
CPT code 43265 describes an endoscopic retrograde cholangiopancreatography (ERCP) procedure that includes endoscopic inspection of the duodenum and the papilla of Vater, followed by radiologic assessment of the pancreatic duct and the biliary tree. The procedure as described for this code also includes stone destruction by any method (for example, mechanical, electrohydraulic, or lithotripsy).
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Service type: Diagnostic and therapeutic endoscopic-radiologic procedure for the pancreaticobiliary system
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Typical site of service: Hospital outpatient department or ambulatory surgical center with radiologic support
Clinical & Coding Specifications
Clinical Context
A 58-year-old patient presents with right upper quadrant abdominal pain, jaundice, and abnormal liver function tests suggesting obstructive biliary disease. Prior imaging (abdominal ultrasound and CT) demonstrates dilatation of the intrahepatic and extrahepatic bile ducts and a suspected common bile duct stone. The gastroenterologist schedules an endoscopic retrograde cholangiopancreatography (ERCP, CPT 43265) for diagnostic cholangiography and definitive stone management.
The clinical workflow includes pre-procedure evaluation (consent, coagulation status, NPO), intravenous sedation or monitored anesthesia care, endoscopic duodenal intubation to identify the major papilla, cannulation of the bile duct, radiologic contrast injection for ductal imaging, and stone destruction using mechanical or lithotripsy methods as needed. Post-procedure monitoring includes assessment for complications (pancreatitis, bleeding, infection, perforation) and disposition planning (recovery unit observation, hospital admission if indicated).
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Default/No modifier | Standard reporting when no modifier applies |