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Billing code 43265: ERCP lithotripsyMedicare rate & RVUs

Reports endoscopic fragmentation of biliary or pancreatic duct stones during ERCP, such as when stones require lithotripsy rather than routine extraction alone.

CMS RVU26DEffective Oct 1, 2026109 payment localities2.1K Medicare services in 2024

Medicare pays $376.76 for 43265 nationally in a facility.

Medicare rate · 43265

ERCP lithotripsy

Swap in your local Medicare rate.

Work RVUs
7.73
Total RVUs
11.28
Global days
000

National rate · 2026

$376.76

Facility setting, before claim adjustments.

See every locality for 43265 → · 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 43265 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 43265 covers

During ERCP, an endoscope is advanced to the duodenum and instruments are passed into the biliary or pancreatic ducts to fragment calculi. A gastroenterologist or other trained endoscopist may use mechanical, electrohydraulic, or laser lithotripsy, often for stones that are difficult to remove intact. These procedures are generally performed in a hospital or ambulatory surgery center.

Report this service when the endoscopist documents active destruction or fragmentation of duct calculi, including the treated duct and method when available. Distinguish it from code 43264 when the service is duct-stone removal without lithotripsy. The CMS 0-day global period includes same-day preoperative and postoperative care. When related endoscopies are performed together, endoscopy family pricing applies. Modifier 50 is inappropriate for this descriptor and anatomy. Medicare does not pay an assistant at surgery for this service; co-surgeons and team surgery 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 43265 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

43265 office and facility rates by payment locality
Payment localityOfficeFacility
AlabamaUnavailable$352.96
Alaska*Unavailable$498.63
ArizonaUnavailable$369.80
ArkansasUnavailable$350.05
AtlantaUnavailable$384.81
AustinUnavailable$379.16
BakersfieldUnavailable$378.90
Baltimore/Surr. CntysUnavailable$394.31
BeaumontUnavailable$366.64
BrazoriaUnavailable$371.63

43265 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
43265 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 43265 rate is calculated

Each of 43265’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 · 43265

RVUs × geographic indexes × conversion factor

Swap in your local Medicare rate.

Work 7.73Practice expense 2.68Malpractice 0.87

11.2800 adjusted RVUs×$33.4009 conversion factor=$376.76

All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.

Payment rules and modifiers for 43265

The CMS indicators that decide how 43265 is paid alongside other services.

CMS payment indicators · 43265

ERCP lithotripsy

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

43265 without 51 · national facility

$376.76

ERCP lithotripsy

43265-51 · Second procedure: 50%

$188.38

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

43265 compared with similar codes

Compare codes

43265 vs 43264 vs 43262 vs 43274: national Medicare rates

Swap in your local Medicare rate.

  • 43265
    ERCP lithotripsy · 7.73 wRVU
    —
  • 43264
    ERCP extraction · 6.46 wRVU
    —
  • 43262
    ERCP sphincterotomy · 6.34 wRVU
    —
  • 43274
    ERCP stenting · 8.27 wRVU
    —

How to choose

43264ERCP extraction
Use 43264 for removal of duct calculi or debris without lithotripsy; 43265 is for active stone destruction or fragmentation.
43262ERCP sphincterotomy
43262 reports sphincterotomy or papillotomy during ERCP. It does not describe fragmentation of duct calculi.
43274ERCP stenting
43274 describes placing a stent in a biliary or pancreatic duct; 43265 describes calculus fragmentation.

Codes related to 43265

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

Codes related to 43265
CodeHow it relatesNational office range
Used instead
43264ERCP extractionDuct-stone removal without the calculus fragmentation service reported with 43265.No office rate
Same family
43260ERCPERCP code for a diagnostic examination with specimen collection.No office rate
43262ERCP sphincterotomyERCP code for sphincterotomy or papillotomy, a distinct duct intervention.No office rate
Often billed with
43274ERCP stentingDuct stent placement may also be performed during an ERCP encounter.No office rate

43265 billing questions

Can stone extraction also be reported after lithotripsy?

Document which services were performed, but do not assume that retrieval of fragmented stones supports a separate code. Related endoscopies performed together are subject to CMS endoscopy family pricing.

Does modifier 50 apply when more than one duct is treated?

No. CMS identifies bilateral adjustment as inapplicable because the descriptor or anatomy makes modifier 50 inappropriate.

What documentation supports reporting 43265?

Document ERCP, the duct and calculi treated, and the lithotripsy or other destruction method. The record should distinguish fragmentation from extraction alone.

Can an assistant surgeon or co-surgeon be paid for 43265?

Medicare does not pay an assistant at surgery for this code. Co-surgeons and team surgery are not permitted.

What does the 0-day global period include?

Same-day preoperative and postoperative care is included in the procedure's payment.

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 43265PPRRVU2026_Oct_nonQPP.csv, line 5,193 (RVU26D)

Open CMS sourceHow we calculate rates

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