No office rate
Both involve EUS-guided needle sampling. Distinguish 43242's intramural or transmural sampling service and included examination from 43238's transmural sampling criteria.
On this page
CMS RVU26D · Effective 2026-10-01
43242 EUS-guided biopsy Medicare reimbursement rates in Vermont
Report this service when upper endoscopy with endoscopic ultrasound guides needle aspiration or biopsy of a lesion in or beyond the gastrointestinal wall. Compare 43242 office and facility rates across CMS payment localities in Vermont.
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 43242 in Vermont?
Vermont 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
$221.12
1 of 1 localities have a supported rate.
Payment area: Vermont
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 43242: Upper endoscopy with EUS-guided needle sampling
Report this service when upper endoscopy with endoscopic ultrasound guides needle aspiration or biopsy of a lesion in or beyond the gastrointestinal wall.
A gastroenterologist typically performs this procedure in a hospital endoscopy unit or ambulatory surgery center. The endoscope and ultrasound imaging are used to evaluate the upper gastrointestinal tract and guide a needle into a target within the wall or through it. Targets may include a subepithelial lesion, a pancreatic mass, or an adjacent lymph node. The service includes the EUS examination of the esophagus, stomach, and either the duodenum or jejunum as appropriate.
Select this code when the documented service includes EUS-guided intramural or transmural needle aspiration or biopsy; a diagnostic EUS without needle sampling is a different service. Document the target, the EUS-guided needle sampling performed, and the examination extent. The 0-day global period includes same-day preoperative and postoperative care. When related endoscopies are performed together, CMS applies endoscopy-family pricing. Modifier 50 is not appropriate for this procedure. Medicare does not pay an assistant at surgery for this service; co-surgeons and team surgery are not permitted.
CMS billing rules for 43242
- 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 RVU4.61 · 67%
- Practice expense (office) RVU1.78 · 26%
- Malpractice RVU0.49 · 7%
26.4K
Medicare services in 2024 · #1027 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.
43242 compared with similar codes
Office rates for Vermont, from the same CMS release.
No office rate
43237 describes diagnostic EUS without needle sampling; 43242 requires EUS-guided aspiration or biopsy.
$411.07
43239 is for upper endoscopic mucosal biopsy, typically with forceps. 43242 uses EUS guidance to direct a needle into a target within or beyond the wall.
No office rate
43232 uses an esophagoscopic approach for EUS-guided needle biopsy. Use 43242 when the documented service is the broader upper endoscopic examination and sampling service.
Compare 43242 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
Vermont →
Office / nonfacility
Unavailable
Facility
$221.12
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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 43242 in Vermont.
PPRRVU2026_Oct_nonQPP.csv
5,170
- Code
- 43242
- Physician work
- 4.61
- Practice expense
- 1.78
- Malpractice
- 0.49
GPCI2026.csv
105
- Locality
- Vermont
- Physician work
- 1.000
- Practice expense
- 0.990
- Malpractice
- 0.506
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 4.61 | × 1.000 | 4.6100 |
| Practice expense | 1.78 | × 0.990 | 1.7622 |
| Malpractice | 0.49 | × 0.506 | 0.2479 |
| Total RVUs | 6.6201 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Vermont$221.12
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 4.61 | 1 |
| Practice expense | 1.78 | 0.99 |
| Malpractice | 0.49 | 0.506 |
(4.61 × 1 + 1.78 × 0.99 + 0.49 × 0.506) × $33.4009 = $221.12
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.
43242 billing questions
How does 43242 differ from 43238?
43242 covers needle sampling of an intramural or transmural target and includes the specified EUS examination. Use 43238 for the transmural sampling service when that code's criteria are met.
Can 43242 be reported for diagnostic EUS without needle sampling?
No. When the EUS examination is performed without needle aspiration or biopsy, consider the diagnostic EUS code that matches the examination extent, such as 43237.
Is a mucosal forceps biopsy included in 43242?
43242 describes EUS-guided needle sampling, not routine mucosal forceps biopsy. Code 43239 represents upper endoscopic mucosal biopsy when its service is performed and separately reportable.
What documentation supports reporting 43242?
Document the EUS examination, the target's location, and the needle aspiration or biopsy performed under ultrasound guidance. The record should support sampling within the wall or through it.
Can modifier 50 be appended when sampling targets on both sides?
No. Modifier 50 is inappropriate for this upper gastrointestinal endoscopic service.
How does Medicare treat related endoscopies performed together?
CMS applies endoscopy-family pricing when related endoscopies are performed together. Same-day preoperative and postoperative care is included in the 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.
5,16743239,,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
5,17043242,,Egd us fine needle bx/aspir,A,,4.61,1.78,NA,1.78,,0.49,6.88,6.88,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,17143243,,Egd injection varices,A,,4.16,1.57,NA,1.57,,0.53,6.26,6.26,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,17243244,,Egd varices ligation,A,,4.29,1.69,NA,1.69,,0.47,6.45,6.45,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
5,17343245,,Egd dilate stricture,A,,3.00,16.19,,1.28,,0.42,19.61,4.70,0,000,0.00,0.00,0.00,3,0,1,0,0,9,43235,33.4009,09,0,99,0.00,0.00,0.00
10204412,TX,18,HOUSTON,1.008,0.993,1.376
10304412,TX,99,REST OF TEXAS,1.000,0.949,0.903
10403502,UT,09,UTAH,1.000,0.940,0.898
10514512,VT,50,VERMONT,1.000,0.990,0.506
10611302,VA,00,VIRGINIA,1.000,0.983,0.706
10709202,VI,50,VIRGIN ISLANDS,1.000,1.011,0.985
10802402,WA,02,SEATTLE (KING CNTY),1.050,1.227,0.817