CPT 43260 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Surgery • Surgical Procedures on the Digestive System |
| Common Place of Service | • 21 - Inpatient Hospital • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • 53 - Discontinued procedure • 52 - Reduced Services |
| Complexity Level | Moderate |
| CMS | $307.62 Physician Fee Schedule |
National average reimbursement for CPT 43260 by major payers:
$425.63
$447.73
$475.63
$546.57
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
Select a payer to view fee schedule data Choose a payer from the options above to see rates for CPT 43260 | ||||||
United | 43260 | $5729.00 | 1679065759 - MEMORIAL HERMANN SURGERY CENTER BRAZORIA, LLC | 830759140 - (TX) MEMORIAL HERMANN SURGERY CENTER BRAZORIA LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $2527.00 | 1386161495 - MEDSTAR SURGERY CENTER AT BRANDYWINE, LLC | 820985178 - (MD) MEDSTAR SURGERY CENTER AT BRAN | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $830.00 | 1215126438 - THE ARCADIA CA ENDOSCOPY ASC LP, VALLEY DIGESTIVE HEALTH CENTER | 204484163 | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $830.00 | 1306851902 - SPECIALTY SURGICAL CENTER OF IRVINE LP | 571149464 - (CA) SPECIALTY SURGICAL CENTER OF IRVINE, LP | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $4898.00 | 1659793891 - INOVA AMBULATORY SURGERY CENTER AT LORTON, LLC | 461955980 - (VA) INOVA AMBULATORY SURGERY CENTER AT LORTON LLC | VA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $2621.00 | 1104082692 - OLD TESSON SURGERY CENTER, L.P., OLD TESSON SURGERY CENTER | 262876334 - (MO) OLD TESSON SURGERY CENTER LP | MO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $1762.00 | 1538122569 - CENTENNIAL SURGERY CENTER LP | 621624530 - (TN) CENTENNIAL SURGERY CENTER LP | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $830.00 | 1700842507 - ARCADIA OUTPATIENT SURGERY CENTER LP | 752285078 - (CA) ARCADIA OUTPATIENT SURGERY CENTER LP | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $1500.00 | 1407251622 - MASSAC COUNTY SURGERY CENTER LLC, THE ORTHOPAEDIC INSTITUTE SURGERY CENTER | 464314954 - (IL) MASSAC COUNTY SURGERY CENTER LLC | IL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $3599.00 | 1497749667 - CALIFORNIA SPECIALTY SURGERY CENTER, LLC, CALIFORNIA SPECIALTY SURGERY CENTER, LLC | 330939003 - (CA) CALIFORNIA SPECIALTY SURGERY CENTER, LP | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $830.00 | 1174538748 - SPECIALTY SURGICAL CENTER, LLC, SPECIALTY SURGICAL CENTER | 954698130 - (CA) SPECIALTY SURGICAL CENTER, LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $2093.00 | 1063715951 - NEW BRITAIN SURGERY CENTER LLC | 273829147 - (PA) NEW BRITAIN SURGERY CENTER, LLC | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $2388.00 | 1184714214 - GAINESVILLE ENDOSCOPY CENTER, LLC | 10750801 - (GA) GAINESVILLE ENDOSCOPY CENTER LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $1542.00 | 1205373057 - BAY AREA ASC LLC, AZURA SURGERY CENTER HOUSTON | 814821022 - (TX) BAY AREA ASC LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43260 | $931.00 | 1487122669 - CONWAY CARDIOVASCULAR SURGERY CENTER, LLC | 832435695 - (AR) CONWAY CARDIOVASCULAR SURGERY CENTER LLC | AR | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 43260 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43260 code is part of the Surgery services used for Surgical Procedures on the Digestive System. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 43260 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 43260-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); Diagnostic Including Collection Of Specimen(S) By Brushing Or Washing When Performed(Separate Procedure) (Revised 01/01/2014) |
| 43263-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); With Pressure Measurement Of Sphincter Of Oddi (Revised 01/01/2014) |
| 43264-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); With Removal Of Calculi/Debris From Biliary/Pancreatic Duct(S) (Revised 01/01/2014) |
| 43265-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); With Destruction Of Calculi Any Method (Eg Mechanical Electrohydraulic Lithotripsy) (Revised 01/01/2014) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43260. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43260 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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