No office rate
Both codes include EUS-guided needle sampling. Choose 43238 for a limited upper-GI examination and 43242 when the examination includes the esophagus, stomach, and duodenum with adjacent structures.
On this page
CMS RVU26D · Effective 2026-10-01
43238 EUS-guided biopsy Medicare reimbursement rates in Colorado
Reports upper endoscopy with ultrasound-guided needle sampling of a lesion in the upper GI wall or an adjacent structure during a limited examination. Compare 43238 office and facility rates across CMS payment localities in Colorado.
Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.
What does Medicare pay for 43238 in Colorado?
Colorado has 1 payment locality in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the payment area shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$206.29
1 of 1 localities have a supported rate.
Payment area: Colorado
One mapped payment locality.
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
Gastrointestinal endoscopy
About 43238: EGD with EUS-guided needle sampling
Reports upper endoscopy with ultrasound-guided needle sampling of a lesion in the upper GI wall or an adjacent structure during a limited examination.
A gastroenterologist performs this service by passing an endoscope through the mouth and using endoscopic ultrasound to guide a needle into a target for aspiration or tissue sampling. Typical targets include a subepithelial stomach lesion, a pancreatic mass, or a suspicious lymph node near the upper gastrointestinal tract. The service is commonly performed in a hospital endoscopy unit or ambulatory endoscopy setting when imaging and tissue acquisition are needed during the same procedure.
Choose 43238 when the EUS examination is limited to the relevant portion of the esophagus, stomach, or duodenum and adjacent structures, and needle sampling is performed. The report should identify the target, ultrasound-guided sampling, and the extent of the examination; the code includes the EUS examination and sampling, rather than a separately billed diagnostic EUS. CMS assigns a 0-day global period, so same-day preoperative and postoperative care is included. Endoscopy family pricing applies when related endoscopies are performed together. Modifier 50 is inappropriate for this anatomy. CMS does not pay an assistant at surgery and does not permit co-surgeon or team-surgery billing for this service.
CMS billing rules for 43238
- Global period
- Minor procedure with a 0-day global period: same-day preoperative and postoperative care is included.
- Multiple procedures
- Endoscopy family pricing applies when related endoscopies are performed together.
- Bilateral procedures
- Bilateral adjustment does not apply; the descriptor or anatomy makes modifier 50 inappropriate.
- Assistant at surgery
- Statutory restriction: assistant at surgery is not paid.
- Co-surgeons
- Co-surgeons not permitted.
- Team surgery
- Team surgery not permitted.
Where the value comes from
- Work RVU4.06 · 66%
- Practice expense (office) RVU1.62 · 26%
- Malpractice RVU0.44 · 7%
17.2K
Medicare services in 2024 · #1203 by national volume
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
43238 compared with similar codes
Office rates for Colorado, from the same CMS release.
No office rate
43237 describes EUS examination without needle sampling. When EUS guides aspiration or biopsy during the procedure, 43238 captures the examination and sampling together.
$439.05
43239 is for endoscopic biopsy of mucosa. Choose 43238 when the endoscopist uses ultrasound to guide a needle into a wall lesion or adjacent target.
No office rate
43232 is the esophagoscopy-based EUS needle-sampling service for an examination limited to the esophagus; 43238 is the EGD-based service for the specified upper-GI examination.
Compare 43238 by payment locality
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
1 of 1 payment localities
Colorado →
Office / nonfacility
Unavailable
Facility
$206.29
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How this local rate is calculated
Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 43238 in Colorado.
PPRRVU2026_Oct_nonQPP.csv
5,166
- Code
- 43238
- Physician work
- 4.06
- Practice expense
- 1.62
- Malpractice
- 0.44
GPCI2026.csv
37
- Locality
- Colorado
- Physician work
- 1.012
- Practice expense
- 1.064
- Malpractice
- 0.781
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 4.06 | × 1.012 | 4.1087 |
| Practice expense | 1.62 | × 1.064 | 1.7237 |
| Malpractice | 0.44 | × 0.781 | 0.3436 |
| Total RVUs | 6.1760 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Colorado$206.29
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 4.06 | 1.012 |
| Practice expense | 1.62 | 1.064 |
| Malpractice | 0.44 | 0.781 |
(4.06 × 1.012 + 1.62 × 1.064 + 0.44 × 0.781) × $33.4009 = $206.29
The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.
43238 billing questions
How does 43238 differ from 43242?
Both include EUS-guided needle sampling. 43238 is for a limited upper-GI EUS examination; 43242 describes examination of the esophagus, stomach, and duodenum with adjacent structures.
Can the diagnostic EUS be billed separately?
The EUS examination that guides the sampling is included in 43238. Do not separately report 43237 for that same examination.
When is 43239 a better fit?
Use 43239 for standard endoscopic biopsy of gastrointestinal mucosa. 43238 is for needle sampling guided by EUS, such as sampling a deeper wall lesion or an adjacent structure.
Does each needle pass count as a separate unit?
The code covers the endoscopic service with needle aspiration or biopsy sampling; it is not reported once for each needle pass.
Is modifier 50 appropriate?
No. The anatomy is not reported as a bilateral service, so modifier 50 is inappropriate.
Can an assistant or co-surgeon be billed?
CMS does not pay an assistant at surgery for this service and does not permit co-surgeon or team-surgery billing.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense, and malpractice RVUs, adjusted by each locality’s geographic indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.
Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.
5,16343235,,Egd diagnostic brush wash,A,,2.04,7.38,,1.03,,0.24,9.66,3.31,0,000,0.00,0.00,0.00,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,16443236,,Uppr gi scope w/submuc inj,A,,2.33,10.76,,1.10,,0.27,13.36,3.70,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,16543237,,Endoscopic us exam esoph,A,,3.38,1.42,NA,1.42,,0.38,5.18,5.18,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,16643238,,Egd us fine needle bx/aspir,A,,4.06,1.62,NA,1.62,,0.44,6.12,6.12,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,16743239,,Egd biopsy single/multiple,A,,2.33,9.94,,1.10,,0.27,12.54,3.70,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,16843240,,Egd w/transmural drain cyst,A,,6.97,2.48,NA,2.48,,0.79,10.24,10.24,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,16943241,,Egd tube/cath insertion,A,,2.43,1.07,NA,1.07,,0.30,3.80,3.80,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
3401112,CA,69,VISALIA,1.017,1.096,0.536
3501112,CA,70,YUBA CITY,1.017,1.096,0.536
3601112,CA,75,REST OF CALIFORNIA,1.017,1.096,0.536
3704112,CO,01,COLORADO,1.012,1.064,0.781
3813102,CT,00,CONNECTICUT,1.020,1.077,1.210
3912202,DC,01,DC + MD/VA SUBURBS,1.054,1.178,1.113
4012102,DE,01,DELAWARE,1.005,0.988,0.899