No office rate
Choose 43261 for tissue biopsy. Choose 43260 when ERCP specimen collection is by brushing or washing.
On this page
CMS RVU26D · Effective 2026-10-01
43261 ERCP Medicare reimbursement rates in Virginia
Reports ERCP with forceps tissue sampling of a biliary or pancreatic duct abnormality, such as a suspected lesion or stricture. Compare 43261 office and facility rates across CMS payment localities in Virginia.
Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.
What does Medicare pay for 43261 in Virginia?
Virginia has 2 payment localities in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the 2 payment areas shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$287.78–$321.91
2 of 2 localities have a supported rate.
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
Gastroenterology
About 43261: ERCP with duct biopsy
Reports ERCP with forceps tissue sampling of a biliary or pancreatic duct abnormality, such as a suspected lesion or stricture.
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.
CMS billing rules for 43261
- Global period
- Minor procedure with a 0-day global period: same-day preoperative and postoperative care is included.
- Multiple procedures
- Endoscopy family pricing applies when related endoscopies are performed together.
- Bilateral procedures
- Bilateral adjustment does not apply; the descriptor or anatomy makes modifier 50 inappropriate.
- Assistant at surgery
- Statutory restriction: assistant at surgery is not paid.
- Co-surgeons
- Co-surgeons not permitted.
- Team surgery
- Team surgery not permitted.
Where the value comes from
- Work RVU6.00 · 68%
- Practice expense (office) RVU2.18 · 25%
- Malpractice RVU0.67 · 8%
6.3K
Medicare services in 2024 · #1728 by national volume
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.
43261 compared with similar codes
Office rates for Virginia, from the same CMS release.
No office rate
43262 represents ERCP with sphincterotomy. Biopsy sampling, rather than sphincterotomy, distinguishes 43261.
No office rate
43264 represents ERCP removal of duct calculi. It is selected for stone extraction, not duct tissue biopsy.
No office rate
43274 represents ERCP duct stent placement. Use 43261 for biopsy; stent placement is a different intervention.
Compare 43261 by payment locality
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
2 of 2 payment localities
Dc + Md/Va Suburbs →
Office / nonfacility
Unavailable
Facility
$321.91
Virginia →
Office / nonfacility
Unavailable
Facility
$287.78
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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 indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.
Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.
5,18643259,,Egd us exam duodenum/jejunum,A,,3.94,1.58,NA,1.58,,0.43,5.95,5.95,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,1874325F,,Med txmnt options rvwd w/pt,M,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00
5,18843260,,Ercp w/specimen collection,A,,5.70,2.09,NA,2.09,,0.62,8.41,8.41,0,000,0.00,0.00,0.00,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,18943261,,Endo cholangiopancreatograph,A,,6.00,2.18,NA,2.18,,0.67,8.85,8.85,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43260,33.4009,09,0,99,0.00,0.00,0.00
5,19043262,,Endo cholangiopancreatograph,A,,6.34,2.28,NA,2.28,,0.70,9.32,9.32,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43260,33.4009,09,0,99,0.00,0.00,0.00
5,19143263,,Ercp sphincter pressure meas,A,,6.34,2.30,NA,2.30,,0.70,9.34,9.34,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43260,33.4009,09,0,99,0.00,0.00,0.00
5,19243264,,Ercp remove duct calculi,A,,6.46,2.32,NA,2.32,,0.72,9.50,9.50,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43260,33.4009,09,0,99,0.00,0.00,0.00