43235 CPT Code (2023) – Description, Guidelines, Reimbursement, Modifiers & Examples

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

43235 CPT Code | Description & Explanation

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

The official description of CPT 43235 is: “Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).”

CPT 43236 can be billed with CPT code 43235 if the physician injects a substance by a submucosa during the Upper GI exam.

Symptoms, Disorders & Treatments

The endoscope is introduced to the patient’s body via the mouth to examine the upper part of the digestive system, such as 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.

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.

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 bodies stuck in the GI tract, control bleeding, perform laser therapy, excision of tumors or polyps, etc.

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 the 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.

Does CPT 43235 Need Modifiers?

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 an annual screening with a family history of polyps.

The physician performed a screening endoscopy procedure (CPT code 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 not usually performed with this service. Modifier XU, XE, XP, and 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 code 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 applies to that subsequent procedure.

Reimbursement

This procedure (CPT 43235) is primarily performed in an ambulatory surgical center or hospital outpatient setting.

The reimbursement rates for CPT 43235, including cost and RUVS are as follows:

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

Billing Guidelines

If bleeding control is done, 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 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.

A reflux test is usually performed by attaching a capsule to the esophageal tissue to visualize the exam better and determine the PH level during the exam, which is transmitted to the recorder and reviewed by the physician.

CPT code 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 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 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.

Billing Examples

The following are four billing examples of the correct usage of CPT code 43235.

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, and recent travel. The patient’s conditions were not better after giving medications, and pain worsened in the upper abdominal region.

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

Billing:

CPT Codes:

• CPT 99203: Office or other outpatient visit for the evaluation and management of a new patient: This code is used for the initial outpatient visit where the patient presented with a severe headache, nausea, vomiting, diarrhea, and body aches.
• CPT 43235: Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure): This code is used to document the EGD procedure performed by the physician to diagnose the problem better.

ICD-10 Codes:

• ICD 10 G44.1: Vascular headache, not elsewhere classified: This code documents the patient’s severe headache.
• ICD 10 R11.0: Nausea: This code documents the patient’s nausea.
• ICD 10 R11.2: Vomiting, unspecified: This code documents the patient’s non-bloody vomiting episodes.
• ICD 10 R19.7: Diarrhea, unspecified: This code is used to document the patient’s episodes of non-bloody diarrhea.
• ICD 10 M79.1: Myalgia: This code documents the patient’s severe body aches.
• ICD 10 Z83.89: Family history of other specified diseases: This code documents the patient’s family history of gastroenteritis diseases.
• ICD 10 I85.00: Esophageal varices without bleeding: This code documents the patient’s diagnosis of 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, primarily 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, and inflammation of upper GI.

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

The patient placed an appointment with a gastroenterologist for EGD.  

Billing:

CPT Codes:

• CPT 99284: Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity: This code is used for the patient’s presentation to the ED with left chest/epigastric pain.
• CPT 74176: Computed tomography, abdomen and pelvis; without contrast material: This code is used to document the CT scan of the abdomen and pelvis ordered to evaluate the patient’s condition.
• CPT 72197: Magnetic resonance (e.g., MRI), pelvis, without and with contrast material(s): This code is used to document the MRI of the abdomen and pelvis region ordered to assess the patient’s condition further.
• CPT 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: This code is used to document the upcoming EGD procedure suggested by the gastroenterologist.

ICD-10 Codes:

• ICD 10 R10.13: Epigastric pain: This code documents the patient’s chief complaint of left chest/epigastric pain.
• ICD 10 K21.9: Gastroesophageal reflux disease without esophagitis: This code documents one of the differential diagnoses, GERD.
• ICD 10 K29.70: Gastritis, unspecified, without bleeding: This code is used to document another differential diagnosis, gastritis.
• ICD 10 K29.90: Gastroduodenitis, unspecified, without bleeding: This code is used to document the inflammation of the upper GI tract found in the diagnostic studies.

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 bloody, watery diarrhea since this morning.

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

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

Billing:

CPT Codes:

• CPT 99284: Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity: This code is used for the patient’s presentation to the ED with epigastric pain, nausea, vomiting, and diarrhea.
• CPT 74176: Computed tomography, abdomen and pelvis; without contrast material: This code is used to document the CT scan of the abdomen and pelvis ordered to evaluate the patient’s condition.
• CPT 72197: Magnetic resonance (e.g., MRI), pelvis, without and with contrast material(s): This code is used to document the MRI of the abdomen and pelvis region ordered to assess the patient’s condition further.
• CPT 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: This code is used to document the upcoming EGD procedure suggested by the GI specialist.

ICD-10 Codes:

• ICD 10 R10.13: Epigastric pain: This code documents the patient’s chief complaint of epigastric pain.
• ICD 10 R11.0: Nausea: This code documents the patient’s nausea.
• ICD 10 R11.2: Vomiting, unspecified: This code is used to document the patient’s vomiting.
• ICD 10 K35.80: Unspecified acute appendicitis without perforation, abscess, or gangrene: This code is used to document one of the differential diagnoses, appendicitis.
• ICD 10 K29.70: Gastritis, unspecified, without bleeding: This code is used to document another differential diagnosis, gastritis.
• ICD 10 K51.90: Ulcerative colitis, unspecified, without complications: This code documents the differential diagnosis of colitis.
• ICD 10 K57.90: Diverticulosis of intestine, part unspecified, without perforation or abscess: This code documents the differential diagnosis of diverticulitis.

Example 4 

A 13-year-old male was 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 or drink anything for 5 hours. He had a choking sensation and was unable to breathe correctly. A physical exam revealed 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 could not move the coin to the intestine.

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

The EGD procedure was done successfully, and the patient’s condition became stable.  

Billing: