CPT 43278 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 | • 22 - On Campus Outpatient Hospital • 21 - Inpatient Hospital |
| Common Modifiers | • None • 51 - Multiple procedures • 59 - Distinct Procedural Service |
| Complexity Level | Moderate |
| CMS | $412.42 Physician Fee Schedule |
National average reimbursement for CPT 43278 by major payers:
$573.20
$611.68
$618.36
$747.93
| 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 43278 | ||||||
United | 43278 | $1698.00 | 1720001928 - CAMPBELL CLINIC SURGERY CENTER, LLC | 621826300 | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $963.78 | 1275687873 - DERMATOLOGY ASSOCIATES OF KENTUCKY, PSC | 610701663 - (KY) DERMATOLOGY ASSOCIATES OF KENTUCKY, P.S.C. | KY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $1507.00 | 1124594338 - CHARLOTTE SURGERY CENTER, LLC | 561449531 - (NC) CHARLOTTE SURGERY CENTER LLC | NC | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $988.00 | 1508813627 - FOUR STATES SURGERY CENTER, PC, FOUR STATES SURGERY CENTER, | 201498725 - (MO) FOUR STATES SURGERY CENTER, PC | MO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $1000.00 | 1093895757 - PATRICK D REEVES MDPA, WILSON SURGICENTER | 412062384 - (TX) PATRICK D. REEVES, M.D., P.A. | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $1290.00 | 1285608075 - PUEBLO CO OPHTHALMOLOGY ASC LLC, ROCKY MOUNTAIN LASER & SURGERY CENTER | 200121336 | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $824.00 | 1679566582 - FOREST CANYON ENDOSCOPY & SURGERY CTR PC | 460504121 - (AZ) FOREST CANYON ENDOSCOPY & SURGERY CENTER, PC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $1475.00 | 1992702443 - THE EASTSIDE ENDOSCOPY CENTER LLC | 911665997 - (WA) THE EASTSIDE ENDOSCOPY CENTER LLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $2900.00 | 1538164546 - SURGERY CENTER AT PELHAM, LLC | 760745215 - (SC) SURGERY CENTER AT PELHAM, LLC | SC | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $3495.00 | 1861538613 - CENTRACARE SURGERY CENTER, LLC | 611514974 | MN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $475.00 | 1285633818 - FOUR CORNERS AMBULATORY SURGICAL CENTER LLC | 522208568 - (MD) FOUR CORNERS AMBULATORY SURGICAL CENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $646.00 | 1235394529 - ACCOMODATIVE SURGERY CENTER, L.L.C., BRECKSVILLE SURGERY CENTER | 203292823 - (OH) ACCOMODATIVE SURGERY CENTER LLC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $1200.00 | 1831665983 - WAXAHACHIE SURGERY CENTER | 831268553 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $1700.00 | 1235692120 - LIBERTY CORNER SURGICAL CENTER AT MARLTON LLC | 833889870 - (NJ) LIBERTY CORNER SURGICAL CENTER AT MARLTON LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43278 | $2105.00 | 1053597161 - 1800 MCDONOUGH ROAD SURGERY CENTER LLC | 261278011 - (IL) 1800 MCDONOUGH ROAD SURGERY CENTER LLC | IL | 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 43278 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43278 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 43278 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 |
|---|---|---|
| 43265-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); With Destruction Of Calculi Any Method (Eg Mechanical Electrohydraulic Lithotripsy) (Revised 01/01/2014) |
| 43274-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); With Placement Of Endoscopic Stent Into Biliary Or Pancreatic Duct Including Pre- And Post-Dilation And Guide Wire Passage When Performed Including Sphincterotomy When Performed Each Stent |
| 43276-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); With Removal And Exchange Of Stent(S) Biliary Or Pancreatic Duct Including Pre- And Post-Dilation And Guide Wire Passage When Performed Including Sphincterotomy When Performed Each Stent Exchanged. |
| 43278-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); With Ablation Of Tumor(S), Polyp(S), Or Other Lesion(S), Including Pre- And Post-Dilation And Guide Wire Passage, When Performed |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43278. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43278 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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