CPT code 43261: ERCP, biopsy2026 Medicare rate & RVUs in Missouri
Reports ERCP with forceps tissue sampling of a biliary or pancreatic duct abnormality, such as a suspected lesion or stricture.
CMS doesn’t publish an office rate for 43261 in Missouri.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
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What 43261 covers
During ERCP, a gastroenterologist advances a side-viewing endoscope through the mouth to the duodenum, accesses the biliary or pancreatic duct, and obtains one or more tissue samples. The service is used to investigate a ductal abnormality, including a suspected tumor or stricture. ERCP is typically performed in a hospital or ambulatory surgery center, often with fluoroscopic guidance.
Report this code when the ERCP includes biopsy; brushing or washing for specimens alone is a different service. The procedure report should identify the sampled site and document the tissue-sampling work. CMS assigns a 0-day global period, so same-day preoperative and postoperative care is included. When related endoscopies are performed together, endoscopy-family pricing applies. Modifier 50 is inappropriate for this service. Medicare does not pay an assistant at surgery, and co-surgeon and team-surgery billing are not permitted.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Where 43261 pays more and less in Missouri
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
| Payment locality | Office | Facility |
|---|---|---|
| Metropolitan Kansas City, MO | Unavailable | $290.64 |
| Metropolitan St. Louis, MO | Unavailable | $292.15 |
| Rest of Missouri | Unavailable | $284.97 |
How the 43261 rate is calculated
Each of 43261’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 43261
RVUs × geographic indexes × conversion factor
Work6.00
6.00 RVUs× 1.000 GPCI
Practice expense2.18
2.18 RVUs× 1.000 GPCI
Malpractice0.67
0.67 RVUs× 1.000 GPCI
Adjusted RVUs
8.8500
Conversion factor
$33.4009
Medicare rate
$295.60
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 43261
The CMS indicators that decide how 43261 is paid alongside other services.
CMS payment indicators · 43261
ERCP, biopsy
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 000 | Same-day global: pre- and post-op care on the day of the procedure is included. |
| Multiple procedures | 3 | Endoscopy family rules apply. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 1 | Not paid (statutory restriction). |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
43261 without 51 · national facility
$295.60
ERCP, biopsy
43261-51 · Second procedure: 50%
$147.80
When this isn’t the highest-valued procedure in the session, Medicare pays 50% of its fee schedule amount (the highest is paid at 100%).
43261 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 43260ERCPBrushing or washing
- Choose 43261 for tissue biopsy. Choose 43260 when ERCP specimen collection is by brushing or washing.
- 43262ERCP sphincterotomyPapillotomy performed
- 43262 represents ERCP with sphincterotomy. Biopsy sampling, rather than sphincterotomy, distinguishes 43261.
- 43264ERCP extractionDuct stones or debris
- 43264 represents ERCP removal of duct calculi. It is selected for stone extraction, not duct tissue biopsy.
- 43274ERCP stentingBiliary or pancreatic duct
- 43274 represents ERCP duct stent placement. Use 43261 for biopsy; stent placement is a different intervention.
43261 billing questions
How is this different from 43260?
Use 43261 when ERCP includes tissue biopsy. Code 43260 describes ERCP with specimen collection by brushing or washing rather than biopsy.
Can brushing or washing be reported with the biopsy?
The biopsy code identifies the tissue-sampling ERCP service. Document each method performed and apply applicable coding edits and endoscopy-family pricing when related endoscopies are reported together.
Does modifier 50 apply if both sides of the biliary system are sampled?
No. CMS identifies bilateral adjustment as inapplicable to this code, and modifier 50 is inappropriate.
Can an assistant surgeon or co-surgeon be billed?
Medicare does not pay an assistant at surgery for this code. Co-surgeons and team surgery are not permitted.
What documentation supports reporting 43261?
The ERCP report should describe the ductal abnormality, the site sampled, and the biopsy performed. It should distinguish tissue biopsy from brushing or washing alone.
Does the code include same-day postoperative care?
Yes. The code has a 0-day global period, which includes same-day preoperative and postoperative care.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
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