CPT 43265
Global 000 ActiveErcp lithotripsy calculi
CPT 43265 Billing & Documentation Guide
CPT code 43265 (Ercp lithotripsy calculi) is classified under Surgery (Digestive) with a global period indicator of 000. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 7.73, a non-facility practice expense RVU of 2.68, and a malpractice RVU of 0.87, a total non-facility RVU of 11.28 and facility RVU of 11.28. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $381.76, though rates vary from $350.05 to $498.63 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 43265, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 43265 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
Endoscopic or minor procedure with related preoperative and postoperative work performed on the same day
MUE Limit (Medically Unlikely Edits)
Submitting more than 1 units of 43265 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 43265
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 7.73 | 7.73 |
| Practice Expense RVU | 2.68 | 2.68 |
| Malpractice RVU | 0.87 | 0.87 |
| Total RVU | 11.28 | 11.28 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 43265
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $389.12 | $389.12 | $376.26 - $431.25 | 29 |
| Florida | $404.57 | $404.57 | $387.44 - $424.86 | 3 |
| Georgia | $378.74 | $378.74 | $372.67 - $384.81 | 2 |
| Illinois | $401.12 | $401.12 | $385.33 - $416.65 | 4 |
| Michigan | $383.14 | $383.14 | $372.72 - $393.56 | 2 |
| North Carolina | $360.27 | $360.27 | $360.27 - $360.27 | 1 |
| New York | $409.8 | $409.8 | $363.66 - $435.11 | 5 |
| Ohio | $369.21 | $369.21 | $369.21 - $369.21 | 1 |
| Pennsylvania | $379.26 | $379.26 | $367.82 - $390.69 | 2 |
| Texas | $374.73 | $374.73 | $366.64 - $389.13 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 43265
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 43265 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 00520 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00731 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00732 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00740 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00810 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00811 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00812 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00813 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 0213T | Column 1 (primary), can be billed with modifier | No | Misuse of Column Two code with Column One code |
| 0216T | Column 1 (primary), can be billed with modifier | No | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 43265
What does CPT code 43265 mean? +
CPT code 43265 represents: Ercp lithotripsy calculi. It's in the Surgery (Digestive) category with a global period of 000.
What is the Medicare reimbursement for CPT 43265? +
The 2026 Medicare national average non-facility payment for CPT 43265 is $381.76. Rates range from $350.05 to $498.63 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 43265? +
Surgery codes commonly use modifier 22 (increased procedural services), 50 (bilateral), 51 (multiple procedures), 52 (reduced services), 58/78/79 (staged, unplanned return, unrelated within global), 62 (co-surgeons), 80/82 (assistant surgeon), and 59 or the X{EPSU} subset for distinct procedural service.
What bundling edits apply to CPT 43265? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on April 17, 2026.
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