CPT Code Overview

CPT 43235 describes a flexible transoral esophagogastroduodenoscopy performed for diagnostic purposes with collection of specimen(s) by brushing or washing. This procedure involves endoscopic visualization of the esophagus, stomach, and duodenum to evaluate upper gastrointestinal symptoms and obtain cytologic samples via brushing or lavage for laboratory analysis.

Service Type: Esophagogastroduodenoscopy Procedures

Typical Site of Service: Outpatient Hospital (POS 22)

A middle-aged outpatient presents to the gastroenterology clinic with several weeks of epigastric pain, intermittent nausea, and reflux symptoms unresponsive to empirical therapy. The patient is scheduled for an outpatient hospital esophagogastroduodenoscopy (EGD) to evaluate the esophagus, stomach, and proximal duodenum. The procedure is performed using a flexible transoral endoscope under moderate sedation. During the diagnostic EGD, the endoscopist performs thorough mucosal inspection and collects cellular material by brushing or washing for cytologic analysis when indicated (e.g., to evaluate suspicious mucosal irregularity or to obtain cytology for evaluation of Barrett-type changes or infectious/inflammatory processes). The typical clinical workflow includes pre-procedure consent and history review, sedation administered by qualified personnel, performance of the 43235 procedure with specimen collection by brushing or washing, recovery and post-procedure instructions, and transmission of specimens to pathology or cytology for interpretation.

Modifiers:

• 26 (Professional Component): Use when reporting only the physician’s professional interpretation or services for the procedure separate from the facility/technical component.

• 51 (Multiple Procedures): Use when 43235 is performed in the same session with other unrelated endoscopic procedures; applies when payer policy requires reduction for additional procedures performed the same day.

• 59 (Distinct Procedural Service): Use when 43235 is a distinct procedure from another service on the same day that is not normally performed together and meets documentation criteria for separate reporting.

• 76 (Repeat Procedure by Same Physician): Use when the same physician repeats 43235 in the postoperative period or later the same day and the payer requires specific reporting for repeats.

Provider Taxonomies:

Notes:

• The listed taxonomies represent specialties commonly performing or referring for 43235 in outpatient hospital settings.
• Facility billing typically uses the hospital’s technical component; professional services by the physician are reported separately as indicated.

Related Diagnoses:

• K21.9 — Gastro-esophageal reflux disease without esophagitis

  Relevance: Reflux symptoms are a common indication for EGD to evaluate mucosal injury or complications such as Barrett esophagus; 43235 may be used during diagnostic evaluation when cytologic sampling is appropriate.

• K25.9 — Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation

  Relevance: EGD is used to visualize gastric ulcers; cytologic brushing/washing may be collected if infection or atypical cells are a concern.

• K29.70 — Gastritis, unspecified, without bleeding

  Relevance: Gastritis presents with epigastric pain and may prompt EGD for diagnosis; brushing/washing can assist in assessing infectious or inflammatory etiologies.

• K31.9 — Disease of stomach and duodenum, unspecified

  Relevance: Non-specific upper GI symptoms prompting EGD often fall under this code; cytology sampling may be performed as part of the diagnostic workup.

• R10.13 — Epigastric pain

  Relevance: Epigastric pain is a common presenting symptom that leads to diagnostic EGD to identify mucosal or structural causes.

• R11.0 — Nausea

  Relevance: Persistent or unexplained nausea can be an indication for EGD to evaluate upper GI pathology; brushing/washing may be done if indicated.

• R19.7 — Diarrhea, unspecified

  Relevance: Diarrhea is less specific for upper GI pathology but may be present in broader GI disease prompting endoscopic evaluation in select cases; 43235 may be reported if EGD with brushing/washing is performed during the diagnostic evaluation.

Related CPT Codes:

Clinical relationship to 43235:

• 43239 is an alternative or additional service when tissue biopsy (forceps) is obtained rather than or in addition to brushing/washing; selection depends on the sampling technique performed.

• 43248 and 43249 describe therapeutic dilation maneuvers that may follow diagnostic evaluation if a stricture is encountered; these are procedure additions when dilation is required.

• 43251 is used when endoscopic removal of lesions or polyps is performed instead of or in addition to diagnostic brushing/washing; it represents a therapeutic escalation.

• 43259 denotes combined endoscopic ultrasound evaluation and is an advanced diagnostic adjunct that may be used in different clinical indications from simple brushing/washing.

Common usage:

• 43235 is commonly used for diagnostic EGD with cytology sampling by brushing or washing. 43239 is commonly used as an alternative when biopsies are taken. Therapeutic codes (43248, 43249, 43251) are commonly reported in the same session when intervention is required; payer rules may require modifier 51 or indicate reduced reimbursement for additional procedures. 43259 is used as an alternative advanced diagnostic modality when endoscopic ultrasound is performed.

National commercial mean rates are generally higher than Medicare for CPT 43235, with BUCA (average commercial) at $292.34 and Medicare at $335.23 showing that Medicare’s mean rate sits above BUCA’s in this dataset. UnitedHealth Group and Cigna report the highest commercial means at $408.71 and $353.40 respectively, while Aetna reports a lower commercial mean at $227.53.

Rate dispersion (P75 minus P25) varies across payers: UnitedHealth Group shows the widest spread (476.00 - 264.00 = $212.00), indicating greater variability; Cigna also has a wide spread (413.33 - 243.50 = $169.83). Aetna displays one of the tightest distributions (255.50 - 162.33 = $93.17), with Medicare similarly tighter (348.00 - 309.00 = $39.00). The table and chart below present the full breakdown of mean rates and percentiles by payer.