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Billing code 43262: ERCP sphincterotomyMedicare rate & RVUs

Reports ERCP in which the endoscopist makes a sphincter incision, commonly to improve duct drainage or enable treatment of biliary stones.

CMS RVU26DEffective Oct 1, 2026109 payment localities23.5K Medicare services in 2024

Medicare pays $311.30 for 43262 nationally in a facility.

Medicare rate · 43262

ERCP sphincterotomy

Swap in your local Medicare rate.

Work RVUs
6.34
Total RVUs
9.32
Global days
000

National rate · 2026

$311.30

Facility setting, before claim adjustments.

See every locality for 43262 → · Billed by an NP, PA or therapist? →

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

On this page 10 sections
  1. Medicare rate
  2. What 43262 covers
  3. By payment locality
  4. Rate map
  5. How it’s calculated
  6. Payment rules
  7. Similar codes
  8. Related codes
  9. Billing questions
  10. Sources

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

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

43262 office and facility rates by payment locality
Payment localityOfficeFacility
AlabamaUnavailable$291.63
Alaska*Unavailable$411.63
ArizonaUnavailable$305.57
ArkansasUnavailable$289.22
AtlantaUnavailable$317.85
AustinUnavailable$313.47
BakersfieldUnavailable$313.49
Baltimore/Surr. CntysUnavailable$325.79
BeaumontUnavailable$302.78
BrazoriaUnavailable$307.16

43262 rates by state

Office rate range in each state. Select a state to see its payment localities.

MEWIVTNHMTNDMNMINYMARIWAIDWYSDIAILINOHPANJCTORNVUTCONEMOKYWVVAMDDECAAZNMKSOKARTNNCSCDCTXLAMSALGAFLAKHI

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Local rates. Clear comparisons.

Hover or focus a tile to see its rate range. Select it to open the state’s fee schedule.

View every state and territory as a table
43262 office rate range by state
State / territoryOffice rate rangeLocalities
AKNo published base rate1
ALNo published base rate1
ARNo published base rate1
AZNo published base rate1
CANo published base rate29
CONo published base rate1
CTNo published base rate1
DCNo published base rate1
DENo published base rate1
FLNo published base rate3
GANo published base rate2
GUNo published base rate1
HINo published base rate1
IANo published base rate1
IDNo published base rate1
ILNo published base rate4
INNo published base rate1
KSNo published base rate1
KYNo published base rate1
LANo published base rate2
MANo published base rate2
MDNo published base rate3
MENo published base rate2
MINo published base rate2
MNNo published base rate1
MONo published base rate3
MSNo published base rate1
MTNo published base rate1
NCNo published base rate1
NDNo published base rate1
NENo published base rate1
NHNo published base rate1
NJNo published base rate2
NMNo published base rate1
NVNo published base rate1
NYNo published base rate5
OHNo published base rate1
OKNo published base rate1
ORNo published base rate2
PANo published base rate2
PRNo published base rate1
RINo published base rate1
SCNo published base rate1
SDNo published base rate1
TNNo published base rate1
TXNo published base rate8
UTNo published base rate1
VANo published base rate2
VINo published base rate1
VTNo published base rate1
WANo published base rate2
WINo published base rate1
WVNo published base rate1
WYNo published base rate1

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

Swap in your local Medicare rate.

Work 6.34Practice expense 2.28Malpractice 0.70

9.3200 adjusted RVUs×$33.4009 conversion factor=$311.30

All indexes start 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

RuleCMS valueWhat it means
Global period000Same-day global: pre- and post-op care on the day of the procedure is included.
Multiple procedures3Endoscopy family rules apply.
Bilateral (modifier 50)0The 150% bilateral adjustment doesn’t apply.
Assistant at surgery (80/81/82/AS)1Not paid (statutory restriction).
Co-surgeons (62)0Not permitted.
Team surgery (66)0Not permitted.
Professional/technical0Physician 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

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%).

When to use modifier 51

43262 compared with similar codes

Compare codes

43262 vs 43260 vs 43261 vs 43263 vs 43264: national Medicare rates

Swap in your local Medicare rate.

  • 43262
    ERCP sphincterotomy · 6.34 wRVU
    —
  • 43260
    ERCP · 5.7 wRVU
    —
  • 43261
    ERCP · 6 wRVU
    —
  • 43263
    ERCP manometry · 6.34 wRVU
    —
  • 43264
    ERCP extraction · 6.46 wRVU
    —

How to choose

43260ERCP
43260 describes ERCP with specimen collection. Choose 43262 when the endoscopist performs a sphincter incision.
43261ERCP
43261 is the ERCP code for biopsy. A biopsy is distinct from the sphincter incision reported with 43262.
43263ERCP manometry
43263 reports ERCP with sphincter pressure measurement. It does not describe the incision that distinguishes 43262.
43264ERCP extraction
43264 reports removal of duct calculi. Use 43262 for the sphincterotomy itself; both services may be performed during the same ERCP.

Codes related to 43262

Related codes aren’t interchangeable: bill the code that matches the service performed.

Codes related to 43262
CodeHow it relatesNational office range
Used instead
43260ERCPUsed for ERCP with specimen collection when the documented service does not include sphincterotomy.No office rate
Often billed with
43264ERCP extractionMay accompany sphincterotomy when the endoscopist also removes duct calculi.No office rate
43274ERCP stentingMay accompany sphincterotomy when ERCP also includes duct stent placement.No office rate

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

Show the CMS file lines behind this rate
RVUs for 43262PPRRVU2026_Oct_nonQPP.csv, line 5,190 (RVU26D)

Open CMS sourceHow we calculate rates

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