$391.13–$435.60
43235 covers diagnostic inspection with brushings or washings when performed. Choose 43239 when forceps biopsy is performed during the upper endoscopy.
On this page
CMS RVU26D · Effective 2026-10-01
43235 Upper GI endoscopy Medicare reimbursement rates in Pennsylvania
Reports a flexible upper endoscopic examination of the esophagus, stomach, and duodenum, including brush or wash cytology when performed without biopsy or therapy. Compare 43235 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 43235 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
$302.00–$335.53
2 of 2 localities have a supported rate.
Facility setting
$107.30–$114.74
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.
Gastroenterology endoscopy
About 43235: Diagnostic upper GI endoscopy with sampling
Reports a flexible upper endoscopic examination of the esophagus, stomach, and duodenum, including brush or wash cytology when performed without biopsy or therapy.
A flexible scope is passed through the mouth to examine the esophagus, stomach, and duodenum. When performed, brushings or washings collect cells or material for laboratory analysis; they are part of this service. Gastroenterologists and other physicians trained in upper endoscopy perform it in office, ambulatory, and hospital settings to evaluate upper gastrointestinal symptoms or findings when the examination is diagnostic.
Report this code when inspection, with or without brushings or washings, is performed without a biopsy or therapeutic intervention. The record should support the examined anatomy, findings, and any sampled site and method. A biopsy or endoscopic treatment calls for the corresponding procedure code rather than separate reporting of this diagnostic examination. Medicare assigns a 0-day global period, so same-day preoperative and postoperative care is included. For multiple procedures in one session, the highest-valued procedure is paid in full and others at 50%. Modifier 50 is inappropriate; assistant-at-surgery services are not paid, and co-surgeons and team surgery are not permitted.
CMS billing rules for 43235
- Global period
- Minor procedure with a 0-day global period: same-day preoperative and postoperative care is included.
- Multiple procedures
- Standard multiple procedure reduction: the highest-valued procedure is paid in full and others at 50% when performed in the same session.
- 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 RVU2.04 · 21%
- Practice expense (office) RVU7.38 · 76%
- Malpractice RVU0.24 · 2%
262.6K
Medicare services in 2024 · #335 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.
43235 compared with similar codes
Office rates for Pennsylvania, from the same CMS release.
No office rate
43237 includes endoscopic ultrasound examination. Choose 43235 for diagnostic inspection without the ultrasound service.
$609.88–$681.67
43245 includes dilation of a stricture during upper endoscopy. 43235 is for diagnostic examination without that therapeutic work.
Compare 43235 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
$335.53
Facility
$114.74
Rest Of Pennsylvania →
Office / nonfacility
$302.00
Facility
$107.30
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43235 billing questions
When should 43239 be reported instead?
Use 43239 when forceps biopsy is performed during the upper endoscopy. Do not separately report this diagnostic examination for the same session.
Are brushings or washings separately billable?
No. Brushings or washings, when performed as part of the diagnostic examination, are included in 43235.
Can 43235 be reported with an endoscopic treatment?
When the same session includes a therapeutic upper endoscopic procedure, report the procedure performed rather than separately reporting the diagnostic examination.
Should modifier 50 be appended?
No. The CMS bilateral adjustment does not apply, and modifier 50 is inappropriate for this service.
How does Medicare handle multiple procedures in one session?
The highest-valued procedure is paid in full; other procedures in the same session are paid at 50%. The 0-day global period includes same-day preoperative and postoperative care.
Can an assistant or co-surgeon be billed for this procedure?
Medicare does not pay an assistant at surgery for this service. Co-surgeons and team surgery are not permitted.
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.
5,16043231,,Esophagoscop ultrasound exam,A,,2.73,1.13,NA,1.13,,0.27,4.13,4.13,0,000,0.00,0.00,0.00,3,0,1,2,0,9,43200,33.4009,09,0,99,0.00,0.00,0.00
5,16143232,,Esophagoscopy w/us needle bx,A,,3.50,1.42,NA,1.42,,0.39,5.31,5.31,0,000,0.00,0.00,0.00,3,0,1,2,0,9,43200,33.4009,09,0,99,0.00,0.00,0.00
5,16243233,,Egd balloon dil esoph30 mm/>,A,,3.97,1.52,NA,1.52,,0.62,6.11,6.11,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,16343235,,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