Summary & Overview
CPT 43278: ERCP with Ablation of Biliary or Pancreatic Lesions
CPT code 43278 represents an endoscopic retrograde cholangiopancreatography (ERCP) procedure that pairs endoscopic inspection of the duodenum and papilla of Vater with radiologic assessment of the pancreatic duct and biliary tree, followed by ablation of one or more lesions. This code describes a combined diagnostic and therapeutic service used in the management of pancreaticobiliary disease, including obstructive lesions and select neoplasms. Nationally, ERCP procedures like this are important for both definitive diagnosis and minimally invasive treatment, reducing the need for more invasive surgical approaches.
Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides readers with benchmarks and comparative coverage perspectives, clinical context for appropriate use of ERCP with ablation, and a summary of billing and coding considerations relevant to facility and professional reporting. Readers will learn about typical settings where CPT code 43278 is performed, common clinical indications, how the service integrates endoscopy and fluoroscopic imaging, and areas where policy updates or payer-specific requirements can affect coverage and claim adjudication. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 43278 describes an endoscopic retrograde cholangiopancreatography (ERCP) procedure that includes endoscopic inspection of the duodenum and the papilla of Vater, radiologic assessment of the pancreatic duct and biliary tree, followed by ablation of one or more lesions. This service combines diagnostic endoscopy with fluoroscopic imaging and a therapeutic ablation step performed during the same encounter.
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Service type: Endoscopic diagnostic and therapeutic procedure (ERCP with lesion ablation)
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Typical site of service: Hospital outpatient department or ambulatory surgical center where endoscopy and radiologic imaging are available
Clinical & Coding Specifications
Clinical Context
A 62-year-old patient with a history of choledocholithiasis presents with right upper quadrant pain, jaundice, and abnormal liver function tests. Cross-sectional imaging suggests dilation of the common bile duct with possible obstructing stone or biliary stricture. After pre-procedure evaluation including coagulation assessment and informed consent, the patient is brought to an endoscopy suite or ambulatory surgical center for endoscopic retrograde cholangiopancreatography (ERCP). Under moderate sedation or monitored anesthesia care, the endoscopist advances a side-viewing duodenoscope to the second portion of the duodenum, identifies the ampulla of Vater, cannulates the biliary and/or pancreatic ducts, and obtains fluoroscopic radiologic assessment of the biliary tree and pancreatic duct. If obstructing lesions (stones, strictures, or mucosal lesions) are identified, the provider performs lesion-directed ablation (for example, endoscopic ablation of biliary or periampullary lesions) in the same session. Post-procedure monitoring occurs in a recovery area with evaluation for complications such as pancreatitis, bleeding, or perforation prior to discharge or inpatient transfer.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Normal, multiple procedures | When ERCP with ablation is the primary service on the same day as other procedures performed by the same provider |