Billing code 43250: Upper endoscopyMedicare rate & RVUs in Guam
Reports upper endoscopic removal of a tumor, polyp, or other lesion using hot biopsy forceps or bipolar cautery.
Medicare pays $545.90 for 43250 in the office in Guam (Hawaii, Guam). Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 43250 covers
During a transoral upper endoscopy, the physician examines the esophagus, stomach, and duodenum and removes a lesion using hot biopsy forceps or bipolar cautery. Gastroenterologists commonly perform this therapeutic procedure in an endoscopy unit or hospital, and it may also be performed in an appropriately equipped office. The defining feature is removal by the specified cautery technique, rather than snare excision or mucosal resection.
Select the code based on the documented removal method, not simply the presence of a lesion. The report should identify the treated site and lesion and describe the technique used. CMS assigns a 0-day global period, so same-day preoperative and postoperative care is included. When related endoscopies are performed together, endoscopy family pricing applies. Modifier 50 is inappropriate for this anatomy and descriptor. Medicare does not pay for an assistant at surgery, and co-surgeons and team surgery are not permitted.
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.
43250 in Hawaii, Guam
| Payment locality | Office | Facility |
|---|---|---|
| Hawaii, Guam | $545.90 | $152.46 |
How the 43250 rate is calculated
Each of 43250’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 43250
RVUs × geographic indexes × conversion factor
Work2.90
2.90 RVUs× 1.000 GPCI
Practice expense11.61
11.61 RVUs× 1.000 GPCI
Malpractice0.42
0.42 RVUs× 1.000 GPCI
Adjusted RVUs
14.9300
Conversion factor
$33.4009
Medicare rate
$498.68
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 43250
The CMS indicators that decide how 43250 is paid alongside other services.
CMS payment indicators · 43250
Upper endoscopy
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 000 | Same-day global: pre- and post-op care on the day of the procedure is included. |
| Multiple procedures | 3 | Endoscopy family rules apply. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 1 | Not paid (statutory restriction). |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
43250 without 51 · national office
$498.68
Upper endoscopy
43250-51 · Second procedure: 50%
$249.34
When this isn’t the highest-valued procedure in the session, Medicare pays 50% of its fee schedule amount (the highest is paid at 100%).
43250 compared with similar codes
Compare codes · National
4 codes, side by side
How to choose
- 43251EGD lesion removal
- Choose 43250 for removal with hot biopsy forceps or bipolar cautery; choose 43251 when a snare is used.
- 43254Endoscopic resection
- 43254 identifies endoscopic mucosal resection. This code is for lesion removal with hot biopsy forceps or bipolar cautery.
- 43239EGD with biopsy
- 43239 is for upper endoscopic biopsy. Use this code when the documented service removes the lesion with the specified cautery technique.
43250 billing questions
How does this differ from 43251?
This code is for lesion removal with hot biopsy forceps or bipolar cautery. Code 43251 describes removal by snare, so the documented technique distinguishes them.
When is 43254 a better choice?
Use 43254 when the physician performs endoscopic mucosal resection. This code instead identifies removal using hot biopsy forceps or bipolar cautery.
Should units be based on the number of lesions?
Document each treated lesion and the technique, but do not assume that each lesion supports a separate unit. The service is an upper endoscopic removal procedure.
What documentation supports this code?
The procedure report should identify the lesion and its location and state that removal was performed with hot biopsy forceps or bipolar cautery.
Can a modifier 50 be used for lesions on both sides?
No. CMS identifies bilateral adjustment as inappropriate for this descriptor and anatomy.
How are related endoscopies handled when performed together?
CMS endoscopy family pricing applies when related endoscopies are performed together. Same-day preoperative and postoperative care is included in this code's 0-day global period.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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