Friday, July 30, 2010

UPPER GASTROINTESTINAL ENDOSCOPY CPT 43235,43236,43238,43241 payments

2010 Medicare GI Endoscopy Procedure Reimbursement Guide for UPPER GASTROINTESTINAL ENDOSCOPY

Surgery Center
Code Procedure Description ASC Facility Fee
(National Medicare Avg)
APC Facility Fee
(National Medicare Avg)²
Fee When
Performed in
Hospital or ASC
(National Medicare Avg)³
Fee When
in Office
(National Medicare Avg)³
43235 Upper gastrointestinal endoscopy including
esophagus, stomach, and either the duodenum
and/or jejunum as appropriate; diagnostic,
with or without collection of specimen(s) by
brushing or washing (separate procedure)
 $342.42    0141    $589.55    $142.90    $280.74  
43236 …with directed submucosal injection(s),
any substance
 $369.45    0141    $589.55    $174.29    $349.30  
43237 …with endoscopic ultrasound examination
limited to the esophagus
 $369.45    0141    $589.55    $233.83    NA*  
43238 …with transendoscopic ultrasound-guide
intramural or transmural fine needle
aspiration/biopsy(s), esophagus (includes
endoscopic ultrasound examination limited to
the esophagus)
 $369.45    0141    $589.55    $292.65    NA*  
43239 …with biopsy, single or multiple  $369.45    0141    $589.55    $170.32    $326.57  
43240 …with transmural drainage of pseudocyst  $369.45    0141    $589.55    $394.04    NA*  
43241 …with transendoscopic intraluminal tube or
catheter placement
 $369.45    0141    $589.55    $154.08    NA*  
43242 …with transendoscopic ultrasound-guided
intramural or transmural fine needle aspiration/
biopsy(s) (includes endoscopic ultrasound
examination of the esophagus, stomach, and
either the duodenum and/or jejunum
as appropriate)
 $369.45    0141    $589.55    $420.39    NA*  
43243 …with injection sclerosis of esophageal and/or
gastric varices
 $369.45    0141    $589.55    $265.58    NA*  
43244 …with band ligation of esophageal and/or
gastric varices
 $369.45    0141    $589.55    $293.73    NA*  
43245 …with dilation of gastric outlet for obstruction
(e.g., balloon, guide wire, bougie)
 $369.45    0141    $589.55    $186.20    NA*  
43246 …with directed placement of percutaneous
gastrostomy tube
 $369.45    0141    $589.55    $250.07    NA*  
43247 …with removal of foreign body  $369.45    0141    $589.55    $198.83    NA*  
43248 …with insertion of guide wire followed by
dilation of esophagus over guide wire
 $369.45    0141    $589.55    $187.64    NA*  
43249 …with balloon dilation of esophagus (less than
30 mm diameter)
 $369.45    0141    $589.55    $172.85    NA*  
43250 …with removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery
 $369.45    0141    $589.55    $186.56    NA*  
43251 …with removal of tumor(s), polyp(s), or other
lesion(s) by snare technique
 $369.45    0141    $589.55    $215.79    NA*  
43255 …with control of bleeding, any method  $369.45    0141    $589.55    $280.38    NA*  
43256 …with transendoscopic stent placement
(includes predilation)
 $917.91    0384    $1,785.67    $252.95    NA*  
43258 …with ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy
forceps, bipolar cautery or snare technique
 $384.76    0141    $598.55    $264.86    NA*  
43259 …with endoscopic ultrasound examination,
including the esophagus, stomach, and either
the duodenum and/or jejunum as appropriate
 $384.76    0141    $598.55    $302.03    NA*  

Indications and Limitations of Coverage and/or Medical Necessity

The following conditions are generally accepted as indications for the performance of EGD(s).

Indications that support EGD(s) for diagnostic purpose(s) are:

Upper abdominal distress that persists despite an appropriate trial of therapy.

Upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g., anorexia and weight loss).

Dysphagia or odynophagia.

Esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy.

Persistent vomiting of unknown cause.

Other system disease in which the presence of upper GI pathology might modify other planned management. Examples include patients with a history of GI bleeding who are scheduled for organ transplantation, long-term anticoagulation, and chronic non-steroidal therapy for arthritis. Please note that this Indication does not provide coverage for routine pre-operative EGD for patients in whom bariatric surgical procedures are contemplated or planned. See LCD S131-AB “Bariatric Surgical Management of Morbid Obesity”.

X-ray findings of: 

A suspected neoplastic lesion for confirmation and specific histologic diagnosis.  Gastric or esophageal ulcer.


Evidence of upper gastrointestinal tract stricture or obstruction.

Gastrointestinal bleeding: 

In most actively bleeding patients.

When surgical therapy is contemplated.

When rebleeding occurs after acute self-limited blood loss.

When portal hypertension or aorto-enteric fistula is suspected.


For presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative.

When sampling of duodenal or jejunal tissue or fluid is indicated.

To assess acute injury after caustic agent ingestion.


Intraoperative EGD when necessary to clarify location or pathology of a lesion.

Indications that support EGD(s) for therapeutic purpose(s) are:

Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g., electrocoagulation, heater probe, laser photocoagulation or injection therapy).

Sclerotherapy and/or band ligation for bleeding from esophageal or proximal gastric varices.

Foreign body removal.

Removal of selected polypoid lesions.

Placement of feeding tubes (per oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy).  Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing guide wires).  Or,
Palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement).

Sequential or periodic diagnostic EGD may be indicated:

For follow up of selected esophageal, gastric or stomal ulcers to demonstrate healing (frequency of follow-up EGD is variable, but every two to four months until healing is demonstrated is reasonable).

For follow up in patients with prior adenomatous gastric polyps (approximate frequency of follow-up EGDs would be every one to four years depending on the clinical circumstances, with occasional patients with sessile polyps requiring every six months surveillance initially), and similarly with surveillance of confirmed high-grade gastric dysplasia.

For follow up for adequacy of prior sclerotherapy and/or band ligation of esophageal varices (approximate frequency of follow-up EGDs is variable depending on the state of the patient but every six to 24 months is reasonable after the initial sclerotherapy sessions are completed).

For follow-up of Barrett’s esophagus (approximate frequency of follow-up EGDs is one to two years with biopsies, unless dysplasia is demonstrated, in which case, a repeat biopsy in two to three months might be indicated).
For follow-up in patients with familial adenomatous polyposis (approximate frequency of follow-up EGDs would be every two to four years, but might be more frequent, such as every six to 12 months, if gastric adenomas or adenomas of the duodenum were demonstrated).

For follow-up of patients with severe, refractory gastroesophageal reflux disease where the concern of malignant degeneration exists (approximate frequency of every ten years)


Upper gastrointestinal endoscopy including esophagus stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing

A previous NCCI update bundled the upper endoscopy, CPT 43235, with the Bravo capsule, CPT 91035. If the endoscopy is performed for the sole purpose of placing the capsule, it is not  separately billable. However, if the endoscopy is performed to examine the esophagus to the duodenum for abnormalities, it can be billed together with the capsule with a 59 modifier on the endoscopy (43235-59).

Code 43234, which described a simple primary upper endoscopy, has been deleted. To report a  diagnostic esophagogastroduodenoscopy, 43235 should be reported, or one of the three diagnostic esophagoscopy codes as appropriate.

Esophagogastroduodenoscopy (EGD) Codes – (43235 – 43259)

 CPT codes 43235-43259 have been placed in the new EGD subsection. These codes have been revised to describe flexible transoral EGD and include five new codes, revision and renumbering of several existing codes and the deletion of two codes. Additionally, the following  qualification to the definition of EGD has been included in the new EGD Guideline language to clarify the appropriate use of modifiers -52 and -53:

To report esophagogastroscopy where the duodenum is deliberately not examined [e.g., judged clinically not pertinent], or because significant situations preclude such exam [e.g., significant gastric retention precludes safe exam of duodenum], append modifier 52 if repeat examination is not planned, or modifier 53 if repeat examination is planned)

Unbundling Unbundling occurs when multiple procedure codes are submitted for a group of procedures that are described by a single comprehensive code. An example of Unbundling would be fragmenting one service into component parts and coding each component as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach is inappropriate (per CMS National Correct Coding Policy Manual).

Beginning with dates of service on or after April 1, 2015, ClaimsXten removed their incidental edit on Current Procedural Terminology (CPT®) code 43235 (esophagogastroduodenoscopy (EGD), flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) when reported with CPT codes 43770-43775 (laparoscopy, surgical, gastric restrictive procedures). However, when an EGD is performed following a gastric restrictive
procedure to confirm there is no leakage, we consider the EGD to be an integral part of the primary procedure and not eligible for separate reimbursement. Therefore, beginning with claims processed on or after August 17, 2015, we will again apply the bundled services incidental edit on CPT code 43235 (EGD) when reported with CPT codes 43770-43775 (gastric restrictive procedures). This information will be documented in Section 2 of our policy.


A new definition and instructions for reporting antegrade transoral small intestine endoscopy (i.e., enteroscopy) have been added to the section guidelines. Enteroscopy is defined by the most distal segment of small intestine that is examined; coding does not reflect the technology used to perform the examination.

Codes in the 44360 family for enteroscopy, not including ileum (44360–44373), are endoscopic procedures to visualize the esophagus through the jejunum using an antegrade approach. Codes in the 44376 family for enteroscopy, including ileum (44376–44379), are endoscopic procedures to visualize the esophagus through the ileum using an antegrade approach.

If an endoscope cannot be advanced at least 50 cm beyond the pylorus, see the appropriate code in the EGD family (43233, 43235–43259, 43266, 43270). If an endoscope can be passed at least 50 cm beyond pylorus, but only into jejunum, see the appropriate code in the enteroscopy, not including ileum family (44360–44373).

To report retrograde examination of small intestine via anus or colon stoma, use 44799, Unlisted procedure, small intestine.

There were no changes to the language of the individual CPT codes.

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