CPT code 43264 – ERCP with calculus removal

Key takeaways

CPT 43264 covers ERCP with removal of stones or debris from the bile or pancreatic duct, while stent removal uses 43275 or 43276.

Breaking stones up by lithotripsy is reported with 43265, which isn’t billed with 43264 for the same stone.

Fluoroscopic supervision (74328, 74329 or 74330) is billed on the professional claim and is typically packaged on the facility claim.

NCCI edits may affect 43262 (sphincterotomy) billed with 43264, so check the current quarterly edit table before billing both.

The 2026 national Medicare physician rate is about $317 (9.50 total RVUs) before locality adjustment, in facility and office settings alike.

CPT code 43264: Full description and procedure overview

CPT code 43264 describes “Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s),” as defined by the American Medical Association’s CPT code set. The code sits within the 43260-43278 ERCP family. That family was restructured in the 2013 CPT update to separate procedures by the intervention performed.

The key clinical distinction is how the stone leaves the duct. CPT 43264 applies when the gastroenterologist uses a basket or balloon to extract a calculus (stone) from the common bile duct or pancreatic duct. Breaking a stone up by mechanical, electrohydraulic or laser lithotripsy is a separate code, 43265. Placing or exchanging a stent without stone extraction also takes a different code from the family.

How the ERCP procedure works: What coders need to know

The operative note is the coder’s main verification tool for CPT 43264. Knowing the procedural sequence helps you confirm the note describes stone removal rather than a different ERCP intervention.

ERCP for calculus removal follows this sequence, and each step needs to appear in the note:

1. Cannulation: The endoscopist advances a duodenoscope to the ampulla of Vater and cannulates the bile duct or pancreatic duct. The note must specify which duct was entered.
2. Fluoroscopic cholangiogram: Contrast is injected under fluoroscopic guidance to show the duct system and locate the calculus. This step supports the separately billable radiology supervision code.
3. Stone extraction: The endoscopist passes a retrieval basket or balloon catheter through the working channel to capture and pull out the stone. If a lithotripter breaks the stone up instead, that work is reported with 43265. The note must confirm extraction, or document the attempt and the reason it failed.
4. Duct sweep: A final balloon sweep confirms clearance. The note should record the number of stones retrieved and their approximate size.
5. Closure and documentation: The endoscopist records the indication, instruments used, duct(s) accessed, any added interventions (sphincterotomy, stent), and the patient’s post-procedure status.

Some notes describe “ERCP with stone extraction” but never say which duct was accessed. Others describe a cholangiogram without confirming extraction. Both leave the claim exposed to a medical necessity denial.

What CPT 43264 includes and excludes

Correct bundling decisions around 43264 start with knowing what the code covers and what needs its own code. Getting this wrong is a frequent source of NCCI edit denials on ERCP claims.

Direct visualization of the duct with a cholangioscope or pancreatoscope is reported with add-on code 43273 on top of 43264. The note has to describe the scope’s view of the stone for the add-on to hold.

CPT 43264 vs related ERCP codes: How to choose the right code

The 43260-43278 ERCP family separates procedures by intervention type. Select the code that matches the intervention documented, not the broadest ERCP descriptor available. A scope that only images the ducts stays at 43260, and each intervention moves the claim to its own code, as the chart below shows.

43264 vs 43262: Calculus removal with or without sphincterotomy

Sphincterotomy (43262) and calculus removal (43264) are distinct procedures, but NCCI edits may treat them as a bundled pair depending on the current quarterly table. Sometimes the endoscopist cuts the sphincter only to reach the stone. Some payers then treat the sphincterotomy as part of the extraction and deny 43262 as a component service.

Others allow separate billing with modifier 59 or modifier XS when the note documents a distinct reason for the sphincterotomy. Check the active NCCI edit pair before billing both codes. Make sure the operative note explains why the sphincterotomy was needed beyond stone access.

43264 vs 43275 and 43276: Calculus removal vs stent procedures

A frequent miscoding in the ERCP family is reporting 43275 (stent or foreign body removal) when 43264 (calculus removal) is correct. Stents and stones both come out through the scope, but the procedure codes are entirely separate. Code 43275 applies when a previously placed stent or a non-calculus foreign body is removed. Code 43264 applies when naturally occurring stones are extracted.

When a session involves both stone extraction and a stent exchange, 43264 and 43276 may both be billable. That depends on NCCI edit status and modifier documentation.

Stent placement after calculus removal: Coding 43264 with 43274 or 43276

After extracting stones, the endoscopist sometimes places a biliary stent to keep the duct draining. This happens most when the duct can’t be fully cleared or swelling is expected after the procedure. When stent placement (43274) happens in the same session as stone removal (43264), both codes are generally billable because they’re distinct therapeutic services.

The operative note must document the clinical indication for each intervention separately. A note that says “ERCP with stone removal and stent placement” without an indication for each won’t defend two procedure codes on audit.

Radiology codes billed with CPT 43264

Fluoroscopic imaging is integral to ERCP. How it’s billed depends on who performs the interpretation and whether the claim is a facility or a professional bill.

On a professional claim, the gastroenterologist who performs and interprets the fluoroscopy bills the matching supervision and interpretation (S&I) code alongside 43264. On a facility claim (hospital outpatient or ASC), fluoroscopy is typically packaged into the facility payment and not separately billable. Confirm with the facility’s billing department, because OPPS packaging rules for radiology codes have changed over time.

ICD-10 diagnosis codes paired with CPT 43264

Linking CPT 43264 to the right ICD-10 diagnosis code is what establishes medical necessity. Payers check the procedure code against the submitted diagnosis to confirm the intervention was clinically indicated. These diagnosis codes support 43264 claims in the common clinical scenarios.

Code to the highest level of specificity available, and use the most specific K80.x code for choledocholithiasis. Don’t report K83.1 (obstruction of bile duct) when a stone causes the blockage. Its Excludes1 note sends cholelithiasis to K80.-, so the obstruction is captured in the K80 code itself.

Medicare MACs apply LCDs, and commercial payers apply their own medical policies. Either may require an obstruction indicator or confirmed cholangitis before ERCP is approved, so check the policy before submitting.

Medicare reimbursement for CPT 43264

Medicare pays the physician for CPT 43264 under the physician fee schedule (PFS), and the hospital under the outpatient prospective payment system (OPPS). For 2026, the code carries 6.46 work RVUs and 9.50 total RVUs in both settings. That puts the national physician rate at about $317 before locality adjustment.

Rates vary by geographic locality and change with each January update. Use the CMS Physician Fee Schedule lookup tool or the FastRVU lookup to find your MAC-specific rate for the current year.

Documentation requirements for CPT 43264

An ERCP operative note that doesn’t confirm stone extraction from a named duct won’t support a 43264 claim on audit. This checklist reflects the documentation standard most payers and Medicare Administrative Contractors (MACs) apply.

• Indication: The clinical reason for the procedure, such as choledocholithiasis confirmed on prior imaging, biliary obstruction symptoms or abnormal liver function tests
• Duct accessed: Explicit identification of the biliary duct, pancreatic duct or both, such as “CBD cannulated” or “main pancreatic duct entered”
• Stone confirmed: Pre-extraction cholangiographic confirmation of the calculus, including approximate size and number when possible
• Extraction method: Retrieval balloon, stone extraction basket or both, with the instrument named. If lithotripsy fragmented the stone, document it separately, because it supports 43265.
• Extraction result: Whether the stone(s) were retrieved and, if clearance was incomplete, the reason (stone size, impaction, patient tolerance)
• Fluoroscopy use: Confirmation that fluoroscopic guidance was used, supporting the companion radiology S&I code
• Additional interventions: A separate clinical indication for any sphincterotomy or stent placement
• Patient status: Post-procedure condition, any immediate complications and disposition

Prior authorization and payer-specific rules for CPT 43264

Medicare: Medicare does not require prior authorization for CPT 43264 in most cases. The procedure still has to meet medical necessity under the applicable Local Coverage Determination (LCD). Some MACs publish LCDs for ERCP that list required ICD-10 codes, prior imaging evidence (MRCP or ultrasound) and clinical criteria. Check your MAC’s LCD list at cms.gov before assuming Medicare will approve the claim.

Commercial payers: Many commercial insurers require prior authorization for ERCP as a high-cost outpatient procedure, particularly for non-emergency presentations. Authorization criteria commonly include:

• A biliary or pancreatic stone documented on imaging
• Abnormal liver function tests or raised bilirubin
• Clinical symptoms consistent with choledocholithiasis

Submit the imaging report and labs with the authorization request. Incomplete submissions are a common reason authorizations are delayed or denied.

Medicaid: Prior authorization rules vary by state Medicaid program. Some states exempt inpatient ERCP from prior authorization, while others require it for outpatient ERCP in all settings. Verify with the state plan and, where applicable, the managed care organization (MCO). Meeting billing compliance requirements at the authorization stage prevents the costliest denial to overturn: a retrospective denial for missing prior authorization.

Common denial reasons for CPT 43264 and how to avoid them

ERCP claims fail for predictable, fixable reasons, and the table pairs each with its remedy. Strong denial management workflows catch most before submission.

For claims denied despite correct coding, the common denial codes reference explains each Claim Adjustment Reason Code (CARC) and helps you build the right appeal. A clean claim submission is still the fastest path to full payment, because every appeal adds weeks.

How Pabau carries the ERCP note into a clean claim

Many of the denials above start at the handoff between the endoscopy note and the claim. A biller retypes the duct, the diagnosis and the radiology code from the report, and one missed field sends the claim back.

Pabau, the practice management platform we build, gives you customizable treatment notes and forms that can capture each field on the documentation checklist. Its cleaner claims management then pulls the data already in the patient record into a pre-filled claim.

The claim goes out through Claim.MD, our US clearinghouse partner, which checks eligibility and tracks each electronic remittance advice after the payer adjudicates. Your team fixes a thin note before submission, instead of reworking a denial weeks later.

Submit cleaner ERCP claims from day one

Pabau captures ERCP documentation in customizable treatment notes and pulls it into a pre-filled claim sent through Claim.MD, with eligibility checks and ERA tracking.

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Conclusion

Treat the operative note as the claim’s source document. If it names the duct, confirms the stones came out and says how, 43264 holds up on audit. If the stones were fragmented instead, the note points to 43265, and the code should follow it.

Sphincterotomy and stent work earn their own codes only when the note gives each one its own indication. Get that sentence written at the time of the procedure, because a physician query after a denial costs far more.

Pabau pulls existing record data into a pre-filled claim sent through Claim.MD, with eligibility checks and ERA tracking along the way. Book a demo to see how a complete ERCP note becomes a claim your team doesn’t have to rework.

Continue your research

Need to understand how clearinghouse claims processing works end to end? Medical claims clearinghouse guide walks through how electronic claims move from practice to payer and where errors enter the pipeline.

Submitting ERCP claims electronically? 837 claim file guide explains the EDI 837P transaction format used to send professional ERCP claims to payers.

Looking for guidance on credentialing before billing ERCP to new payers? Insurance credentialing guide covers the enrollment steps a gastroenterologist completes before billing Medicare and commercial payers.

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