Summary & Overview
CPT 43249: Esophagogastroduodenoscopy with Balloon Dilation of Esophagus
CPT code 43249 is a nationally recognized billing code for esophagogastroduodenoscopy (EGD) with transendoscopic balloon dilation of the esophagus, targeting strictures less than 30 mm in diameter. This procedure is a cornerstone in gastroenterology, enabling clinicians to diagnose and treat esophageal narrowing caused by a range of benign and malignant conditions. The code is most commonly utilized in facility outpatient settings, such as hospital outpatient departments, where advanced endoscopic equipment and clinical expertise are available.
Major payers including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare provide coverage for this procedure, reflecting its clinical importance and widespread use. The publication offers a comprehensive overview of clinical indications, relevant ICD-10 diagnoses, and associated billing modifiers. Readers will gain insights into national benchmarks, policy updates, and the clinical context surrounding the use of 43249, as well as comparisons to related CPT codes for similar endoscopic interventions.
This summary serves as a resource for understanding the procedural, billing, and policy landscape for esophageal balloon dilation via EGD, equipping stakeholders with the information needed to navigate payer requirements and clinical documentation standards.
CPT Code Overview
CPT code 43249 describes an esophagogastroduodenoscopy (EGD) procedure performed with a transendoscopic balloon dilation of the esophagus using a flexible, transoral approach. The dilation is specifically for esophageal strictures less than 30 mm in diameter. This service is categorized under gastroenterology and is a type of digestive system endoscopy. The procedure is typically performed in a facility outpatient setting, such as a hospital outpatient department, where specialized equipment and clinical support are available. The use of balloon dilation allows for the treatment of esophageal narrowing, improving patient outcomes in cases of benign or malignant strictures.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult presenting with symptoms of esophageal narrowing, such as difficulty swallowing (dysphagia), which may be due to benign or malignant neoplasms, strictures, or inflammation. The patient is referred to a gastroenterologist for evaluation. After clinical assessment and imaging, the provider determines that endoscopic dilation is indicated. In a facility outpatient setting, the provider performs an esophagogastroduodenoscopy (EGD) using a flexible, transoral scope. During the procedure, a transendoscopic balloon is used to dilate the esophagus to less than 30 mm diameter, addressing the underlying obstruction or narrowing. The workflow includes pre-procedure assessment, sedation, endoscopic visualization, balloon dilation, and post-procedure monitoring.
Coding Specifications
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Modifiers:
Modifier Description Usage 26Professional Component Used when only the physician's professional services are billed, not the facility or equipment. TCTechnical Component Used when only the technical (facility/equipment) portion is billed. 59Distinct Procedural Service Used to indicate a procedure or service was distinct or independent from other services performed on the same day. 51Multiple Procedures Used when multiple procedures are performed during the same session. -
Provider Taxonomies:
Taxonomy Code Specialty 207RG0100XGastroenterology Physician 207Q00000XFamily Medicine Physician 207R00000XInternal Medicine Physician
These specialties are authorized to perform and bill for the procedure described by CPT code 43249.
Related Diagnoses
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B37.81- Candidal esophagitis- Relevant for patients with esophageal inflammation and narrowing due to fungal infection.
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C15.3- Malignant neoplasm of upper third of esophagus- Indicates cancer in the upper esophagus, which may cause obstruction requiring dilation.
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C15.4- Malignant neoplasm of middle third of esophagus- Cancer in the middle esophagus, potentially leading to stricture.
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C15.5- Malignant neoplasm of lower third of esophagus- Cancer in the lower esophagus, often associated with dysphagia and need for dilation.
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C15.8- Malignant neoplasm of overlapping sites of esophagus- Cancer involving multiple esophageal regions, possibly causing complex strictures.
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C15.9- Malignant neoplasm of esophagus, unspecified- Used when the exact location of esophageal cancer is not specified.
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C16.0- Malignant neoplasm of cardia- Cancer at the stomach's cardia, which may affect the esophagus and require dilation.
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C16.1- Malignant neoplasm of fundus of stomach- Cancer in the stomach's fundus, potentially impacting the esophagus.
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C16.2- Malignant neoplasm of body of stomach- Cancer in the stomach body, may cause upper GI symptoms.
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C16.3- Malignant neoplasm of pyloric antrum- Cancer in the pyloric antrum, possibly leading to upper GI obstruction.
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C16.4- Malignant neoplasm of pylorus- Cancer in the pylorus, may affect gastric emptying and esophageal function.
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C16.5- Malignant neoplasm of lesser curvature of stomach, unspecified- Cancer in the lesser curvature, may be associated with upper GI symptoms.
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C16.6- Malignant neoplasm of greater curvature of stomach, unspecified- Cancer in the greater curvature, may impact GI tract.
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C16.8- Malignant neoplasm of overlapping sites of stomach- Cancer involving multiple stomach regions.
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C16.9- Malignant neoplasm of stomach, unspecified- Used when the exact location of stomach cancer is not specified.
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C17.0- Malignant neoplasm of duodenum- Cancer in the duodenum, may cause upper GI obstruction.
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C25.0- Malignant neoplasm of head of pancreas- Pancreatic cancer, may cause upper GI symptoms.
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C25.1- Malignant neoplasm of body of pancreas- Cancer in the pancreas body, may impact GI tract.
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C25.2- Malignant neoplasm of tail of pancreas- Cancer in the pancreas tail, may cause GI symptoms.
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C25.3- Malignant neoplasm of pancreatic duct- Cancer in the pancreatic duct, may affect GI function.
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C25.4- Malignant neoplasm of endocrine pancreas- Cancer in the endocrine pancreas, may impact GI tract.
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C25.7- Malignant neoplasm of other parts of pancreas- Cancer in other pancreatic regions.
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C25.8- Malignant neoplasm of overlapping sites of pancreas- Cancer involving multiple pancreatic regions.
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C25.9- Malignant neoplasm of pancreas, unspecified- Used when the exact location of pancreatic cancer is not specified.
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C49.A1- Gastrointestinal stromal tumor of esophagus- Tumor in the esophagus, may cause obstruction requiring dilation.
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C49.A2- Gastrointestinal stromal tumor of stomach- Tumor in the stomach, may impact esophageal function.
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C49.A3- Gastrointestinal stromal tumor of small intestine- Tumor in the small intestine, may cause upper GI symptoms.
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C7A.092- Malignant carcinoid tumor of the stomach- Carcinoid tumor in the stomach, may cause GI symptoms.
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C78.4- Secondary malignant neoplasm of small intestine- Metastatic cancer in the small intestine, may cause obstruction.
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C88.40- Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] not having achieved remission- Lymphoma affecting GI mucosa, may cause strictures.
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D00.1- Carcinoma in situ of esophagus- Early-stage esophageal cancer, may require intervention.
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D00.2- Carcinoma in situ of stomach- Early-stage stomach cancer, may impact GI tract.
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D01.7- Carcinoma in situ of other specified digestive organs- Early-stage cancer in other digestive organs.
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D01.9- Carcinoma in situ of digestive organ, unspecified- Used when the exact location is not specified.
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D13.0- Benign neoplasm of esophagus- Benign tumor causing esophageal narrowing.
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D13.1- Benign neoplasm of stomach- Benign tumor in the stomach, may impact esophageal function.
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D13.2- Benign neoplasm of duodenum- Benign tumor in the duodenum, may cause upper GI symptoms.
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D13.30- Benign neoplasm of unspecified part of small intestine- Benign tumor in small intestine, may cause GI symptoms.
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D13.39- Benign neoplasm of other parts of small intestine- Benign tumor in other small intestine regions.
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D37.1- Neoplasm of uncertain behavior of stomach- Tumor of uncertain behavior in the stomach, may require monitoring or intervention.
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D37.2- Neoplasm of uncertain behavior of small intestine- Tumor of uncertain behavior in small intestine.
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D37.3- Neoplasm of uncertain behavior of appendix- Tumor of uncertain behavior in appendix.
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D37.4- Neoplasm of uncertain behavior of colon- Tumor of uncertain behavior in colon.
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D37.5- Neoplasm of uncertain behavior of rectum- Tumor of uncertain behavior in rectum.
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D37.6- Neoplasm of uncertain behavior of liver, gallbladder and bile ducts- Tumor of uncertain behavior in liver, gallbladder, or bile ducts.
Related CPT Codes
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43248- Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by dilation of passage of dilator(s) through esophagus over guide wire- Used when dilation is performed using a guide wire and dilators, rather than balloon dilation. May be an alternative to
43249depending on clinical indication.
- Used when dilation is performed using a guide wire and dilators, rather than balloon dilation. May be an alternative to
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43250- Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery- Used when lesions are removed during EGD using hot biopsy forceps or cautery. Can be performed in the same session as
43249if both dilation and lesion removal are needed.
- Used when lesions are removed during EGD using hot biopsy forceps or cautery. Can be performed in the same session as
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43251- Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique- Used for removal of lesions by snare technique during EGD. May be performed together with
43249if clinically indicated.
- Used for removal of lesions by snare technique during EGD. May be performed together with
These codes are related by their use in endoscopic procedures of the upper GI tract and may be used as alternatives or in conjunction with 43249 depending on the clinical scenario.
National Reimbursement Benchmarks
Medicare's national mean rate for CPT code 43249 stands at $1,234.23, which is notably higher than the BUCA (average commercial) mean rate of $750.14. Among commercial payers, UnitedHealth Group and Cigna also report elevated mean rates, at $1,222.13 and $860.03 respectively, while Aetna is the lowest at $493.70.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Aetna exhibits the tightest range ($301.17), indicating less variability in rates, while UnitedHealth Group shows the widest range ($782.67), reflecting substantial rate variation. Medicare's range is $168.00, also relatively tight compared to most commercial payers.
The table and chart below present the full breakdown of national benchmarks for CPT code 43249 across major payers.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.