43235 CPT code

43235 CPT Code (2022) – Description, Guidelines, Reimbursement, Modifiers & Examples

43235 CPT code is used to bill services rendered by the physician to diagnose and treat upper GI (Gastrointestinal) complications.

The endoscope will be introduced to the patients’ body via the mouth to examine the upper part of the digestive system like the esophagus, intestines, and stomach.

An endoscope comprises a long flexible tube, and a small camera is incorporated on one end to capture imaging inside the body.

43235 CPT Code Description

43235 CPT code is performed to extract a tissue sample for diagnostic biopsies or treat bleeding in the upper GI tract.

It will allow examining the esophagus, stomach, duodenum, and in some cases jejunum to treat and diagnose multiple upper GI disorders like ulcers, tumors, bleeding, erosion, or other disorder of the upper GI tract.

CPT 43235 will be billed when the biopsy sample can be extracted by brushing or washing technique on the stomach lining with saline along with aspiration.

CPT 43236 is billed in combination with CPT code 43235 if the physician injected a substance by a submucosa during the Upper GI exam.

The following list is of treatments, disorders, and symptoms for when CPT 43235 is used:

Symptoms: Sudden weight loss, Difficulty in swallowing, Upper abdominal pain, chest pain not related to the heart, and frequent emesis.

Disorders: Stomach ulcers, esophageal varices, blockage, inflammation or stricture in upper GI tract, GERD (gastroesophageal reflux disease), etc.

Problem Treatments: eliminate foreign body stuck in GI tract, control bleeding, perform laser therapy, excision of tumors or polyps, etc.

43235 cpt code description

CPT code 43235 is performed to diagnose and treat Upper GI tract problems which include:

  • Flexible endoscopic tube along with the camera on one end
  • Enter into body transorally
  • Specimens collections by brushing or washing

Any additional substance injected through the scope during the procedure will be separately reportable with CPT code 43236.

CPT Code 43235 Modifiers

There is the following list of modifiers that are applicable to append with CPT 43235:

59, XS, XU, XE, XP, 52, 53, 51, 58, 63, 76, 77, 78, 79, 99, AQ, AI, AR, CR, CC, ET, EY, GA, Gj, GC, GK, GJ, GR, GY, GU, GZ, KX, PT, QJ, Q5, Q6, SG

Modifiers 52, 53, 51, 59, 78, 79, 58 are the most frequently billed modifiers with CPT 43235.

Modifier PT will be appended with 43235 CPT code when the screening procedure of Upper GI is converted into a diagnostic procedure. For Instance, the patient presents to the office for annual screening with a family history of polyps.

The physician performed a screening endoscopy procedure (CPT 43235) and found a polyp in the findings. He decides to remove polyps from the upper GI tract.

In this scenario, Modifier PT will be attached to CPT 43235 when billed to Medicare insurance, while modifier 33 for commercial insurance if appropriate.

CPT 43235 will be billed with modifier 59 if it is bundled with other services that are not usually performed with this service. Modifier XU, XE, XP, XS will be billed instead of modifier 59 when insurance is Medicare to reflect the most accurate condition.

Modifier 52 is applicable with CPT 43235 when the physician does not study the duodenum due to unavoidable circumstances and does not plan the procedure in the future or deliberately.

In contrast, modifier 53 will be appended with CPT 43235 when the physician does not examine the duodenum and plan to redo the procedure.

CPT 43235 will be performed with Evaluation and Management (E/M) CPT codes on the same day with the unrelated condition. Modifier 59 will be appended with CPT 43235 and 59 with E/M CPT CODES (99201- 99499).

If the encounter is the same, then E/M CPT codes will be written off on the claim. While Modifier 24 is applicable when E/M service is done in the postoperative period with an unrelated condition.

CPT 43235 is performed, and the physician plans to do another procedure in the global period. Modifier 58 is applicable with that subsequent procedure.

cpt code 43235

Reimbursement

This procedure (CPT 43235) is mostly performed in an ambulatory surgical center, hospital outpatient setting. CPT 43235 Cost and RUVS are as follow:

  • Facility: Cost $133.18, RUVS 3.84832
  • Non-Facility: Cost $356.82, RUVS 10.31082

Billing Guidelines

If bleeding control is done, which is related to an endoscopic procedure (CPT 43235) in the same operative session, it is included in CPT 43235 and not separately billable.

If CPT 43235 is performed in combination with Bravo™ reflux testing equipment (CPT 91035) is separately reportable. Modifier 26 or TC will be appended with CPT 91035, and modifier 59 will be attached to CPT 43235 because of the lower RUVS value. Reflux test is usually performed by attaching capsule to the esophageal tissue to better visualize the exam and determine the PH level during the exam, which is transmitted to the recorder and reviewed by the physician.

CPT 43235 diagnostic procedure is performed with surgical endoscopy. It is included in the CPT 43235 and not separately reportable.

CPT 43243 will be only reported when EGD is performed in conjunction with sclerosis injection of Gastric varices. CPT 43235 will not be reported separately.

CPT 43235 is mostly part of more complex procedures or services, and it is not separately reportable. Complex procedures CPTs are as follows:

CPT’s 43197–43198, 43210, 43236–43259, 43266, 43270, 44360–44361, 44363–44366, 44369–44370, 44372–44373, or 44376–44379.

If moderate sedation is performed with CPT code 43235, it is billed with appropriate CPT and HCPCS codes (99156, 99157, 99152, 99153, G0500).

Appropriate ICD 10 codes will be required if related to the procedure according to their respective LCD and NCD. 

CPT 43235 includes Gastric intubation whether it is performed with or without aspiration (CPT codes 43753, 43754, 43756). These CPT codes are not separately reportable. If CPT 43235 is performed to facilitate Gastric intubation, it is appropriate to bill CPT codes (43753, 43754, 43756) with modifier 52.

43235 CPT Code Examples

The following are examples of when EGD service 43235 is performed:

Example 1

This morning, a 20-year-old male presented to the office with a severe headache, nausea, approximately eight episodes of non-bloody vomiting, and three episodes of non-bloody diarrhea with severe body aches.

He also had a family history of gastroenteritis diseases. The patient denies fever, chills, urinary complaints, chest pain, cough, back pain, recent travel. Patient conditions were not better by giving medications, and pain became worse in the upper abdominal region.

He denies any weight changes and no jaundice. He was unable to eat and drink anything. The physician decided to EGD to diagnose the problem better. EGD revealed that the patient has esophageal varices.  

Example 2 

A 51 years-old male who denies any past medical history presented to ED with Left chest/epigastric pain x 5 days on and off, mostly constant now, burning in nature, 9 out of 10, and worse on exertion.

He is unable to take any food. He denies shortness of breath, diaphoresis, nausea, vomiting, cough, hemoptysis, palpitations, leg pain, or swelling.

No excessive belching, flatus, diarrhea, constipation, fever, or chills were reported. Physical exams revealed that pain is related to upper GI despite heart-related and differential dx were GERD, gastritis, inflammation of upper GI.

Diagnostic studies like CT and MRI of the abdomen and pelvis region were performed and revealed that Upper GI is severely inflamed. The doctor consulted with a Gerontologist, and he suggested doing EGD to treat the inflamed GI tract.

The patient placed an appointment with a gastroenterologist for EGD.  

Example 3 

A 47-year-old female presented to the emergency department with complaints of epigastric pain, nausea, vomiting, and diarrhea since this morning.

The patient states that she woke up this morning with symptoms and has had many episodes of bilious vomiting and had bloody watery diarrhea since this morning.

She states that she has never faced any problem previously. The patient denies numbness, tingling, headache, itching. The physician performed diagnostic studies to reveal the problem and ordered medications like IV fluids, Pepcid, Toradol, Zofran to treat diarrhea and pain.

The pain was getting worse after medications. Physical exam revealed that differential dx are Appendicitis, gastritis, colitis, diverticulitis. The physician decided to do EGD after the consulted with a GI specialist. CPT and MRI of the abdomen show abnormal findings.  

Example 4 

A 13-year-old male is presented to the emergency department with no significant past medical history after accidentally swallowing a coin and being stuck in the esophageal junction.

He is unable to eat and drink anything for 5 hours. He had a choking sensation and was unable to breathe properly. Physical exam revealed that the patient had a foreign body at esophageal junctions, while the rest were reviewed and negative.

The physician orders a chest x-ray to confirm the position of the foreign body in the stomach. The physician tried to remove the foreign body with tools but was unable to move the coin to the intestine.

The patient was seen by a gastroenterologist and planned to do EGD for removal of foreign body. EGD procedure was done to pass the coin to the intestine and will be automatically removed by a bowel movement.

EGD procedure was done successfully, and patient conditions became stable.  

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