CPT code 43265: ERCP lithotripsy2026 Medicare rate & RVUs in Texas
Reports endoscopic fragmentation of biliary or pancreatic duct stones during ERCP, such as when stones require lithotripsy rather than routine extraction alone.
CMS doesn’t publish an office rate for 43265 in Texas.
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 9 sections
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 in Texas
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
8 of 8 payment localities
| Payment locality | Office | Facility |
|---|---|---|
| Austin | Unavailable | $379.16 |
| Beaumont | Unavailable | $366.64 |
| Brazoria | Unavailable | $371.63 |
| Dallas | Unavailable | $374.60 |
| Fort Worth | Unavailable | $374.08 |
| Galveston | Unavailable | $373.20 |
| Houston | Unavailable | $389.13 |
| Rest Of Texas | Unavailable | $369.38 |
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
Work7.73
7.73 RVUs× 1.000 GPCI
Practice expense2.68
2.68 RVUs× 1.000 GPCI
Malpractice0.87
0.87 RVUs× 1.000 GPCI
Adjusted RVUs
11.2800
Conversion factor
$33.4009
Medicare rate
$376.76
Every GPCI starts 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
| 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
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%).
43265 compared with similar codes
Compare codes · National
4 codes, side by side
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.
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
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