Billing code 43196: Esophageal dilationMedicare rate & RVUs in Oregon
A flexible transoral esophagoscopy code for widening an esophageal narrowing by passing a dilator over a guidewire placed during the procedure.
CMS doesn’t publish an office rate for 43196 in Oregon.
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 43196 covers
A physician passes a flexible scope through the mouth to examine the esophagus, guides a wire across a narrowing, and dilates the narrowed area over that wire. Otolaryngologists and gastroenterologists commonly perform this for benign strictures, rings, webs, or narrowing at a surgical anastomosis. The service is directed to the esophagus; when the procedure includes examination or treatment extending into the stomach or duodenum, consider the applicable upper gastrointestinal endoscopy code instead.
Report this service when the documented technique includes guidewire placement and dilation over the wire, rather than balloon dilation or diagnostic examination alone. The record should identify the indication and narrowed site and describe the guidewire-assisted dilation performed. 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; assistant-at-surgery payment is restricted, 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.
Where 43196 pays more and less in Oregon
| Payment locality | Office | Facility |
|---|---|---|
| Portland | Unavailable | $174.97 |
| Rest Of Oregon | Unavailable | $167.02 |
How the 43196 rate is calculated
Each of 43196’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 · 43196
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 3.23Practice expense 1.46Malpractice 0.45
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 43196
The CMS indicators that decide how 43196 is paid alongside other services.
CMS payment indicators · 43196
Esophageal dilation
| 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
43196 without 51 · national facility
$171.68
Esophageal dilation
43196-51 · Second procedure: 50%
$85.84
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%).
43196 compared with similar codes
Compare codes
43196 vs 43195 vs 43226 vs 43220 vs 43197: national Medicare rates
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How to choose
- 43195Esophageal dilation
- 43195 describes rigid esophagoscopy with balloon dilation. This code is for flexible esophagoscopy using guidewire-assisted dilation.
- 43226Esophageal dilation
- Both involve guidewire-assisted dilation, but 43226 is the relevant upper gastrointestinal endoscopy alternative when the service extends beyond the esophagus.
- 43220Esophageal dilation
- 43220 represents balloon dilation in an upper gastrointestinal endoscopy service; this code describes dilation over a guidewire during esophagoscopy.
- 43197Esophagoscopy
- 43197 is diagnostic transnasal esophagoscopy. It does not describe the therapeutic guidewire dilation reported with this code.
43196 billing questions
When should this code be chosen over 43226?
Use this code for guidewire-assisted dilation during esophagoscopy limited to the esophagus. Code 43226 is the relevant comparison when the service is an upper gastrointestinal endoscopy that includes examination beyond the esophagus.
How does this differ from balloon dilation?
This code represents dilation over a guidewire. A balloon dilation technique is represented by a different code, such as 43220 when the service meets that code's scope and requirements.
Can diagnostic esophagoscopy be reported separately?
The examination is part of the therapeutic esophagoscopy session. Do not report a separate diagnostic examination for the same work simply because the esophagus was inspected before dilation.
What documentation supports reporting this service?
Document the indication and location of the narrowing, placement of the guidewire, and dilation performed over the wire. The record should distinguish this technique from balloon dilation.
Can modifier 50 or an assistant-at-surgery claim be used?
No. CMS identifies bilateral adjustment as inappropriate for this service and restricts assistant-at-surgery payment. Co-surgeons and team surgery are also not permitted.
How does the 0-day global period affect same-day care?
Same-day preoperative and postoperative care is included in the procedure'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
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