No office rate
43195 describes rigid esophagoscopy with balloon dilation. This code is for flexible esophagoscopy using guidewire-assisted dilation.
On this page
CMS RVU26D · Effective 2026-10-01
43196 Esophageal dilation Medicare reimbursement rates in Pennsylvania
A flexible transoral esophagoscopy code for widening an esophageal narrowing by passing a dilator over a guidewire placed during the procedure. Compare 43196 office and facility rates across CMS payment localities in Pennsylvania.
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 43196 in Pennsylvania?
Pennsylvania has 2 payment localities in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the 2 payment areas shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$166.86–$178.52
2 of 2 localities have a supported rate.
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 43196: Flexible esophagoscopy with guidewire dilation
A flexible transoral esophagoscopy code for widening an esophageal narrowing by passing a dilator over a guidewire placed during the procedure.
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.
CMS billing rules for 43196
- 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 RVU3.23 · 63%
- Practice expense (office) RVU1.46 · 28%
- Malpractice RVU0.45 · 9%
350
Medicare services in 2024 · #3864 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.
43196 compared with similar codes
Office rates for Pennsylvania, from the same CMS release.
$387.42–$432.35
Both involve guidewire-assisted dilation, but 43226 is the relevant upper gastrointestinal endoscopy alternative when the service extends beyond the esophagus.
$884.96–$997.04
43220 represents balloon dilation in an upper gastrointestinal endoscopy service; this code describes dilation over a guidewire during esophagoscopy.
$185.15–$205.07
43197 is diagnostic transnasal esophagoscopy. It does not describe the therapeutic guidewire dilation reported with this code.
Compare 43196 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.
2 of 2 payment localities
Metropolitan Philadelphia →
Office / nonfacility
Unavailable
Facility
$178.52
Rest Of Pennsylvania →
Office / nonfacility
Unavailable
Facility
$166.86
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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 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.
5,13443193,,Esophagoscp rig trnso biopsy,A,,2.72,1.30,NA,1.30,,0.41,4.43,4.43,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43191,33.4009,09,0,99,0.00,0.00,0.00
5,13543194,,Esophagoscp rig trnso rem fb,A,,3.42,0.94,NA,0.94,,0.48,4.84,4.84,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43191,33.4009,09,0,99,0.00,0.00,0.00
5,13643195,,Esophagoscopy rigid balloon,A,,2.99,1.35,NA,1.35,,0.43,4.77,4.77,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43191,33.4009,09,0,99,0.00,0.00,0.00
5,13743196,,Esophagoscp guide wire dilat,A,,3.23,1.46,NA,1.46,,0.45,5.14,5.14,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43191,33.4009,09,0,99,0.00,0.00,0.00
5,13843197,,Esophagoscopy flex dx brush,A,,1.48,4.21,,0.36,,0.21,5.90,2.05,0,000,0.00,0.00,0.00,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,13943198,,Esophagosc flex trnsn biopsy,A,,1.77,4.51,,0.43,,0.25,6.53,2.45,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43197,33.4009,09,0,99,0.00,0.00,0.00
5,14043200,,Esophagoscopy flexible brush,A,,1.38,7.00,,0.79,,0.21,8.59,2.38,0,000,0.00,0.00,0.00,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00