How To Use CPT Code 43264

CPT 43264 describes a specific procedure known as endoscopic retrograde cholangiopancreatography (ERCP) with the removal of calculi or debris from the biliary or pancreatic ducts. This article will provide an overview of CPT code 43264, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 43264?

CPT 43264 is a code used to describe the procedure of endoscopic retrograde cholangiopancreatography (ERCP) with the removal of calculi or debris from the biliary or pancreatic ducts. This procedure involves the use of a scope inserted through the mouth and down into the duodenum to inject contrast material into the ducts. The provider then uses X-ray imaging to identify any disorders and removes stones or debris using various techniques, such as a basket or balloon sweep.

2. Official Description

The official description of CPT code 43264 is: ‘Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s).’ It is important to note that this code should not be reported if no calculi or debris are found, even if a balloon catheter is deployed. Additionally, it should not be reported in conjunction with CPT codes 43260 or 43265. For percutaneous removal of calculi or debris, CPT code 47544 should be used.

3. Procedure

1. The provider administers anesthesia to the patient.
2. A scope is inserted through the patient’s mouth and down into the duodenum.
3. Retrograde dye or contrast material is injected into the biliary and pancreatic ducts.
4. X-ray images are obtained using a fluoroscope to identify any disorders.
5. If stones or debris are found, the provider may use a basket over a guidewire to trap and remove them.
6. A balloon may be inserted to assist in the removal of stones.
7. The stones or debris are withdrawn into the duodenum.

4. Qualifying circumstances

CPT 43264 is typically performed on patients who have calculi or debris in their biliary or pancreatic ducts. The procedure is used to remove these obstructions and restore proper function. It is important to note that this code should not be reported if no calculi or debris are found during the procedure. Additionally, it should not be reported in conjunction with CPT codes 43260 or 43265, as these codes represent different procedures.

5. When to use CPT code 43264

CPT code 43264 should be used when the provider performs an ERCP procedure and successfully removes calculi or debris from the biliary or pancreatic ducts. It is important to note that this code should not be reported if no calculi or debris are found during the procedure, even if a balloon catheter is deployed. If the removal of calculi or debris is performed percutaneously, CPT code 47544 should be used instead.

6. Documentation requirements

To support a claim for CPT code 43264, the provider must document the following information:

• Patient’s diagnosis indicating the presence of calculi or debris in the biliary or pancreatic ducts
• Details of the procedure, including the use of contrast material and any specific techniques employed for stone or debris removal
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional interventions performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 43264, it is important to ensure that the procedure meets the criteria outlined in the official description. This includes the removal of calculi or debris from the biliary or pancreatic ducts. It should not be reported if no calculi or debris are found during the procedure, even if a balloon catheter is deployed. Additionally, it should not be reported in conjunction with CPT codes 43260 or 43265. If the removal of calculi or debris is performed percutaneously, CPT code 47544 should be used instead.

8. Historical information

CPT code 43264 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been two code changes. On January 1, 2002, the code was changed to specify the removal of stone(s) from the biliary and/or pancreatic ducts. On January 1, 2014, the code was further revised to include the removal of calculus/calculi from the biliary and/or pancreatic ducts.

9. Examples

1. A patient undergoes an ERCP procedure with the removal of calculi from the biliary ducts.
2. A provider performs an ERCP procedure and successfully removes debris from the pancreatic duct.
3. An individual with a diagnosis of biliary obstruction undergoes an ERCP procedure with the removal of calculi from both the biliary and pancreatic ducts.
4. A patient presents with symptoms of pancreatitis and undergoes an ERCP procedure with the removal of debris from the pancreatic duct.
5. A provider performs an ERCP procedure and successfully removes calculi from the biliary ducts using a basket over a guidewire.