CPT code 43262: ERCP sphincterotomy, papillotomy performed2026 Medicare rate & RVUs in Missouri
Reports ERCP in which the endoscopist makes a sphincter incision, commonly to improve duct drainage or enable treatment of biliary stones.
CMS doesn’t publish an office rate for 43262 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 43262 covers
During ERCP, a gastroenterologist advances an endoscope to the major papilla and uses an endoscopic cutting instrument to incise the biliary or pancreatic sphincter. The opening can facilitate duct drainage or allow treatment such as removing common bile duct stones. This service is generally performed in a hospital or ambulatory endoscopy setting when imaging or other evaluation indicates a need for therapeutic duct access, including biliary obstruction or choledocholithiasis.
Report this code when the procedure record supports that a sphincterotomy or papillotomy was actually performed, not merely planned or considered. Document the indication, the site of the incision, and the therapeutic work completed. The code has a 0-day global period, so same-day preoperative and postoperative care is included. When related endoscopies are performed together, CMS endoscopy family pricing applies. Modifier 50 is inappropriate; an assistant at surgery is not paid under the statutory restriction, and co-surgeon and team-surgery payment 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 43262 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 | $306.11 |
| Metropolitan St. Louis, MO | Unavailable | $307.69 |
| Rest of Missouri | Unavailable | $300.18 |
How the 43262 rate is calculated
Each of 43262’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 · 43262
RVUs × geographic indexes × conversion factor
Work6.34
6.34 RVUs× 1.000 GPCI
Practice expense2.28
2.28 RVUs× 1.000 GPCI
Malpractice0.70
0.70 RVUs× 1.000 GPCI
Adjusted RVUs
9.3200
Conversion factor
$33.4009
Medicare rate
$311.30
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 43262
The CMS indicators that decide how 43262 is paid alongside other services.
CMS payment indicators · 43262
ERCP sphincterotomy, papillotomy performed
| 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
43262 without 51 · national facility
$311.30
ERCP sphincterotomy, papillotomy performed
43262-51 · Second procedure: 50%
$155.65
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%).
43262 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 43260ERCPBrushing or washing
- 43260 describes ERCP with specimen collection. Choose 43262 when the endoscopist performs a sphincter incision.
- 43261ERCPBiopsy
- 43261 is the ERCP code for biopsy. A biopsy is distinct from the sphincter incision reported with 43262.
- 43263ERCP manometrySphincter of Oddi pressure
- 43263 reports ERCP with sphincter pressure measurement. It does not describe the incision that distinguishes 43262.
- 43264ERCP extractionDuct stones or debris
- 43264 reports removal of duct calculi. Use 43262 for the sphincterotomy itself; both services may be performed during the same ERCP.
43262 billing questions
How does this differ from 43260?
Use 43262 when the ERCP includes a sphincterotomy or papillotomy. Code 43260 describes an ERCP with specimen collection rather than this sphincter incision.
Can duct stone removal be reported with this code?
Code 43264 describes duct calculus removal and may be reported for that work when both procedures are performed. The operative report should make the sphincterotomy and stone-removal services clear.
What documentation supports reporting 43262?
The ERCP report should identify the clinical indication and document that the endoscopist performed an incision of the biliary or pancreatic sphincter.
Should modifier 50 be appended?
No. CMS identifies bilateral adjustment as inapplicable to this code, so modifier 50 is inappropriate.
Is same-day postoperative care separately included?
No. The 0-day global period 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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