Gastroenterology Coding Alert

Get the clarity you need to confidently code ERCP procedures and secure proper reimbursement.

If you’re a medical coder working in gastroenterology, you know that endoscopic retrograde cholangiopancreatography (ERCP) procedures come with layers of complexity — not just clinically, but in how they’re documented and billed. Codes in the 43261-43265 and 43275-43278 ranges can look deceptively similar, but each one captures a distinct therapeutic action that impacts reimbursement. Add in bundled services, imaging requirements, and modifier rules, and it’s easy to see how mistakes can slip in.

In this guide, we’ll walk through how to accurately code these procedures, what supporting documentation payers expect, and how to navigate the nuances that can make or break clean claims.

Break Down the CPT^® Code Ranges

First, you should familiarize yourself with these two series of ERCP codes.

Background: ERCP represents a specialized procedure that combines endoscopy and fluoroscopy (X-ray imaging) to diagnose and treat conditions in the bile ducts, pancreatic duct, and gallbladder. A diagnostic ERCP is primarily used to identify or confirm a problem in the bile or pancreatic ducts, while a therapeutic ERCP means that the procedure includes fixing the problem. Finally, advanced ERCPs are more complex and involve newer or more technically challenging techniques.

Check out this rundown of ERCP codes and when to use them:

43261-43265: Diagnostic and Therapeutic Interventions

• 43261 (Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple): You’ll use this code when the gastroenterologist obtains tissue samples from the bile or pancreatic ducts for histological examination.
• 43262 (… with sphincterotomy/papillotomy): This code applies when the gastroenterologist cuts the sphincter to facilitate access or drainage.
• 43263 (… with pressure measurement of the sphincter of Oddi): You typically use this code in cases of suspected sphincter dysfunction.
• 43264 (… with removal of calculi/debris from biliary/pancreatic duct(s)): This code indicates active therapeutic removal of stones or sludge.
• 43265 (… with destruction of calculi, any method (e.g., mechanical, electrohydraulic, lithotripsy)): You’ll report this code when calculi are fragmented for easier removal.

43275-43278: Advanced Therapeutic Procedures

• 43275 (… with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s)): This is distinct from 43261 in terms of technique the gastroenterologist uses.
• 43276 (… with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged): Notice how this code descriptor includes all prep work and sphincterotomy if performed.
• 43277 (… with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct): This code includes sphincterotomy when performed.
• 43278 (… with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed): This code represents the therapeutic destruction of lesions or growths.

Understand What Codes You Should Not Report Together

Bundling rules per CPT^® instructions and National Correct Coding Initiative (NCCI) edits restrict how you can bill certain codes together.

For instance, you should not report 43264 (stone removal) with 43265 (stone destruction). Report 43265 only if both removal and destruction are performed.

Also, NCCI bundles code 43262 (sphincterotomy) with:

• 43274 (… with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent)
• 43276 for the stent removal/exchange

Do not report 43262 separately when either of these procedures is billed.

Code 43277 includes sphincterotomy when performed. Do not separately bill 43262 with 43277.

Using modifier 59: If two procedures are typically bundled but are performed at distinct sites or represent separate sessions, you may append modifier 59 (Distinct procedural service). Always consult NCCI when considering modifier 59. When the modifier indicator is “1,” you can apply a modifier to separately report these procedures so long as you have supporting documentation.

Pay Attention to Reimbursement Requirements for Documentation and Imaging

You should always choose CPT^® codes based on your physician’s documentation. Thorough operative documentation is essential. The report should clearly describe the following:

• Whether the target duct(s) were biliary, pancreatic, or both
• Access technique (guidewire, balloon, basket, dilation, etc.)
• Number and type of therapeutic maneuvers performed
• Any complications managed
• Rationale for each procedure

Example: If you’re thinking you want to report 43278 for tumor ablation, the op report should include the lesion’s size, location, ablation method, and post-procedural status.

Fluoroscopic guidance is inherent to ERCP and assumed in coding, but images should still be archived and accessible for audit or payer review. Radiologic documentation may include the following:

• Pre- and post-treatment ductal images
• Contrast injections showing ductal patency or obstruction
• Confirmation of stone or lesion removal

Note: If your physician does separate diagnostic imaging outside the scope of an ERCP (e.g., magnetic resonance cholangiopancreatography [MRCP] or endoscopic ultrasound [EUS]) prior to ERCP, you may report those procedures separately with appropriate documentation.

You Do Have an Unlisted Code Option for ESWL

If extracorporeal shock wave lithotripsy (ESWL) is used outside the scope of traditional ERCP codes, you can use 47999 (Unlisted procedure, biliary tract). You will need to include the following:

• Procedure description
• Operative note
• Comparison to a similar reimbursable CPT^® code for pricing support

Code Smarter for Better Payment

Accurate coding for ERCP hinges on understanding the CPT^® code ranges 43261-43265 and 43275-43278, along with the bundling rules and required clinical evidence. Ensure that your documentation and imaging meet payer expectations and be ready to use modifiers or unlisted codes when your case doesn’t fit the mold.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor