2025 CPT code 43261
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Endoscopic retrograde cholangiopancreatography (ERCP) with biopsy, single or multiple.
Modifiers may be applicable depending on the circumstances of the procedure.For example, modifier 59 may be used to indicate a distinct procedural service if multiple procedures were performed during the same session.
Medical necessity for ERCP with biopsy is established when clinical findings suggest a biliary or pancreatic pathology requiring tissue diagnosis. This might include abnormal imaging studies, elevated liver enzymes, unexplained abdominal pain, or other clinical indicators that warrant tissue sampling for pathological evaluation.The physician must clearly document the clinical findings to support the medical necessity of the procedure.
The physician's responsibilities include inserting the endoscope, cannulating the biliary and/or pancreatic ducts, injecting contrast media, obtaining fluoroscopic images, taking biopsies, and interpreting the findings.Post-procedural care and monitoring are also the responsibility of the physician.
In simple words: The doctor uses a thin, flexible tube with a camera (endoscope) to examine the bile and pancreatic ducts. A special dye is injected to help get clearer pictures. The doctor also collects tissue samples for testing.
This CPT code encompasses the endoscopic retrograde cholangiopancreatography (ERCP) procedure, which involves the insertion of an endoscope into the duodenum to visualize the biliary and pancreatic ducts.Contrast material is injected to enhance imaging, and one or more biopsies of suspicious tissues are taken during the procedure. The procedure may involve various techniques and levels of complexity depending on the findings and needs of the patient.
Example 1: A 55-year-old female presents with abdominal pain and elevated liver enzymes. ERCP with biopsy is performed to investigate the cause of these symptoms.Multiple biopsies are taken from suspicious areas within the bile ducts., A 70-year-old male with a history of gallstones undergoes ERCP for stone removal. During the procedure, the physician encounters an area of stricture requiring dilation. A single biopsy is taken for histological examination to rule out malignancy., A 40-year-old female with recurrent pancreatitis undergoes ERCP for ductal exploration and tissue sampling.The procedure reveals abnormal ductal structures, and multiple biopsies are taken from various locations within the pancreatic duct.
Complete medical history, including symptoms, physical examination findings, and prior diagnostic studies.Pre-procedure consent form.Detailed operative report, including the type and number of biopsies taken, location of biopsies, and findings.Anesthesiologist's report if sedation was given.Pathology report of the biopsy specimen(s).Post-operative care instructions and follow up plan.Radiological imaging including fluoroscopic images obtained during the procedure.
** Accurate coding of ERCP procedures depends on precise documentation of the procedures and services performed. Consider consulting with a qualified coding specialist for complex cases.
- Revenue Code: P8B (Endoscopy - Upper Gastrointestinal)
- Payment Status: Active
- Specialties:Gastroenterology, Hepatology, Surgical Oncology
- Place of Service:Office, Hospital Outpatient, Ambulatory Surgical Center