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.
Sign up for cpt 43265 policy alerts
Get alerted when payer policies referencing 43265 are released or updated.
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).
-
Service type: Diagnostic and therapeutic endoscopic-radiologic procedure for the pancreaticobiliary system
-
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 |
22 | Increased procedural services | Use when work, time, or technical difficulty is substantially greater than usual |
52 | Reduced services | Use when the procedure is partially reduced or not completed as documented |
53 | Discontinued procedure | Use when procedure is terminated due to patient condition or safety concerns |
59 | Distinct procedural service | Use to indicate a separate and distinct procedure or service |
62 | Two surgeons | Use when two surgeons of different specialties share the operative procedure |
73 | Discontinued outpatient hospital/ambulatory surgery prior to anesthesia | Use when scheduled ERCP is stopped before anesthesia is administered |
78 | Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period | Use if a return procedure is required for the same episode |
80 | Assistant surgeon | Use when an assistant surgeon participates in the procedure |
81 | Minimum assistant surgeon | Use for a lesser assisting role |
82 | Assistant surgeon (when qualified resident not available) | Use when assistant is required and no resident available |
59 | Distinct procedural service (see above) | See row above for guidance |
52 | Reduced services (see above) | See row above for guidance |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207VG0300X | Gastroenterology | Physicians who perform diagnostic and therapeutic ERCP |
| 208VP0000X | General Surgery | Surgeons who may perform complex biliary interventions |
| 208800000X | Anesthesiology | Providers who provide sedation/monitored anesthesia care for ERCP |
| 207RH0000X | Interventional Gastroenterology | Advanced endoscopists specializing in therapeutic ERCP |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
K80.1 | Choledocholithiasis | Common bile duct stones are a primary indication for ERCP with stone destruction |
K83.1 | Obstruction of bile duct | Biliary obstruction from stones or strictures often mandates ERCP evaluation and therapy |
K85.9 | Acute pancreatitis, unspecified | Pancreatitis may be caused by biliary obstruction and can prompt therapeutic ERCP |
K83.0 | Cholestasis | Cholestatic liver tests with imaging findings can lead to ERCP for diagnosis and intervention |
K83.8 | Other specified diseases of biliary tract | Miscellaneous biliary pathology that may require ERCP for diagnosis or therapy |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
43264 | Endoscopic retrograde cholangiopancreatography, diagnostic, including sphincterotomy if performed | Diagnostic ERCP closely related when no stone destruction is performed; may be used for initial diagnostic evaluation |
43266 | ERCP with cannulation of pancreatic duct, includes diagnostic radiologic evaluation and therapeutic interventions | Used when pancreatic duct access or therapy is required in addition to biliary work |
43267 | ERCP with removal of biliary or pancreatic duct stones by balloon or basket | Alternative or adjunct technique for stone extraction when fragmentation is not required |
43268 | ERCP with endoscopic placement of prosthetic biliary stent | Used when stent placement is performed for biliary decompression after stone removal or if obstruction persists |
47562 | Laparoscopic cholecystectomy with cholangiography | May be performed before or after ERCP in the broader management of biliary stone disease |