Endoscopy Procedure Codes: CPT 43235 & CPT 43239

• Endoscopy is a less invasive diagnostic and therapeutic procedure used in modern medicine to examine the interior surfaces of an organ or tissue. Two of the most frequently used CPT (Current Procedural Terminology) codes for upper gastrointestinal endoscopy are CPT 43235 and CPT 43239.
• These medical codes are essential for medical billing and coding professionals to accurately document procedures and ensure proper reimbursement.
• In our latest blog, we’ll delve into the details of these two codes, their applications, and the key differences between them.

Exploring Upper Gastrointestinal Endoscopy

An upper gastrointestinal (GI) endoscopy, also called an esophagogastroduodenoscopy (EGD), is a procedure that uses a flexible tube with a camera to examine the lining of the esophagus, stomach, and the first part of the small intestine (duodenum). It is used to diagnose and sometimes treat conditions such as ulcers, inflammation, tumors, and bleeding.

Endoscopy procedures are coded in the CPT manual under the “Digestive System” section, which includes a variety of diagnostic and therapeutic endoscopic procedures.

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CPT 43235- Diagnostic Esophagogastroduodenoscopy

CPT 43235 refers to a diagnostic EGD. This procedure is performed to inspect the upper GI tract for abnormalities, collect visual data, or obtain biopsies. This code is specific to cases where no significant additional therapeutic or surgical interventions are performed during the procedure.

The full definition of CPT 43235 is:
Esophagogastroduodenoscopy is flexible and transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).

Use of CPT 43235

CPT 43235 is appropriate when the procedure is purely diagnostic, such as:

• Evaluating symptoms like abdominal pain, nausea, vomiting, or difficulty swallowing.
• Investigating causes of gastrointestinal bleeding.
• Monitoring conditions like Barrett’s esophagus or gastritis.

It is important to note that if a biopsy or therapeutic intervention is performed during the procedure, a different code—such as CPT 43239—should be used.

CPT 43239- Esophagogastroduodenoscopy with Biopsy

CPT 43239 refers to an EGD with biopsy. This code is used when the physician performs a diagnostic endoscopy and removes tissue samples for pathological examination. The full definition of CPT 43239 is:
Esophagogastroduodenoscopy is flexible and transoral; with biopsy, it is single or multiple.

Use of CPT 43239

This code is applied when the endoscopist identifies abnormal areas in the upper GI tract and collects tissue samples. Examples of conditions requiring biopsies include:

• Suspected cancerous or precancerous lesions.
• Unexplained ulcers or masses.
• Chronic conditions like celiac disease or eosinophilic esophagitis.

It’s worth noting that CPT 43239 covers single or multiple biopsies within the same procedure, so there is no need to list the code multiple times if more than one biopsy is taken.

Differences Between CPT-43235 and CPT-43239

While both codes describe upper GI endoscopy procedures, their application depends on the nature of the procedure performed. Below are the primary distinctions:

Aspect	CPT 43235	CPT 43239
Procedure Type	Diagnostic only	Diagnostic with biopsy
Purpose	Visual inspection, brushing/washing	Tissue sample removal for pathology
Use of Tools	No biopsy tools	Includes use of biopsy forceps or tools
Coding Complexity	Simple diagnostic coding	Includes additional procedure details

Documentation and Regulatory Requirements

Accurate documentation is critical for billing the correct CPT code. Key elements include:

1. Reason for the Procedure: Document the symptoms or conditions necessitating the endoscopy.
2. Procedure Notes: Describe the findings, actions taken, and any additional interventions.
3. Pathology Requests: For CPT 43239, include details of the biopsy, such as the number of samples taken and their locations.
4. Images and Reports: Maintain visual records and detailed procedure notes to support the coding.

How to Prevent Common Coding Errors

1. Confusing CPT 43235 with CPT 43239: If a biopsy is performed, always use CPT 43239. Assigning CPT 43235 instead could lead to claim denials or underpayment.
2. Unbundling Codes: Avoid separately coding brushing, washing, or specimen collection, as these are included in both CPT 43235 and CPT 43239.
3. Lack of Specificity: Vague documentation can result in incorrect coding. Always provide detailed procedural notes.
4. Not Checking Payer Guidelines: Some payers may have specific rules for billing these codes. Verify payer policies for coverage and reimbursement requirements.

Reimbursement Insights CPT Codes

Reimbursement for these procedures varies based on the payer, geographical location, and facility type. CPT 43239 generally commands a higher reimbursement rate than CPT 43235 due to the added complexity of the biopsy procedure.

To maximize reimbursement:

• Ensure documentation supports the selected CPT code.
• Use ICD-10 diagnosis codes that accurately reflect the reason for the procedure.
• Confirm the patient’s insurance coverage and pre-authorization requirements.

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Clinical Scenarios for Clarification

1. Scenario 1: A patient presents with persistent nausea and vomiting. The physician performs an EGD, observes mild gastritis, and concludes without further intervention.
   CPT Code: 43235.
2. Scenario 2: A patient undergoes an EGD due to suspected celiac disease. During the procedure, the physician collects multiple biopsies from the duodenum.
   CPT Code: 43239.
3. Scenario 3: A patient experiences GI bleeding. The physician performs an EGD, identifies a lesion, and collects a tissue biopsy for analysis.
   CPT Code: 43239.

The Bottom Line:

Understanding and correctly applying CPT codes 43235 and 43239 is essential for accurate medical billing and proper reimbursement. While CPT 43235 is used for diagnostic endoscopies, CPT 43239 covers procedures involving biopsies. Both codes play a vital role in the diagnosis and management of upper GI conditions.

For healthcare providers and coding professionals, staying updated on CPT guidelines and payer-specific rules ensures compliance, reduces claim denials, and improves revenue cycle efficiency.