No office rate
Both codes address repair of an esophageal opening; choose 43420 for the cervical approach and 43425 for the thoracic approach.
On this page
CMS RVU26D · Effective 2026-10-01
43420 Esophageal repair Medicare reimbursement rates in Virginia
Reports operative repair of an esophageal opening through a cervical approach, including repair associated with an esophageal diverticulum. Compare 43420 office and facility rates across CMS payment localities in Virginia.
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 43420 in Virginia?
Virginia 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
$851.02–$962.25
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.
Esophageal surgery
About 43420: Cervical esophageal opening repair
Reports operative repair of an esophageal opening through a cervical approach, including repair associated with an esophageal diverticulum.
43420 describes operative repair of an esophageal opening reached through the neck. A typical situation is reconstruction after addressing an esophageal diverticulum. The surgeon closes or reconstructs the esophageal defect; this is an operative service, generally performed in a hospital operating room by a surgeon such as a thoracic or head-and-neck surgeon. The cervical route distinguishes this code from the thoracic approach in the same code family.
Select the code based on the operative approach and the nature of the defect. The operative report should identify the opening being repaired, the cervical approach, and the work performed; repair of an esophageal wound or injury is represented by different codes. CMS assigns a 90-day global period, including the day-before preoperative visit and related postoperative care. For multiple procedures in one session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% reduction. Modifier 50 is inappropriate. Assistant-at-surgery payment requires medical-necessity documentation, co-surgeon payment requires supporting documentation, and team-surgery payment is not permitted.
CMS billing rules for 43420
- Global period
- Major surgery with a 90-day global period: the day-before preoperative visit and 90 days of related postoperative care are 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
- Assistant at surgery is paid only with documentation of medical necessity.
- Co-surgeons
- Co-surgeons paid only with supporting documentation.
- Team surgery
- Team surgery not permitted.
Where the value comes from
- Work RVU16.36 · 62%
- Practice expense (office) RVU7.56 · 29%
- Malpractice RVU2.39 · 9%
26
Medicare services in 2024 · #5757 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.
43420 compared with similar codes
Office rates for Virginia, from the same CMS release.
No office rate
43410 describes repair of an esophageal wound or injury through a cervical approach. 43420 is for repair of an esophageal opening, such as one associated with a diverticulum.
No office rate
43415 describes repair of an esophageal wound or injury through a thoracic approach. For repair of an opening, distinguish the cervical route of 43420 from the thoracic route of 43425.
Compare 43420 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
Dc + Md/Va Suburbs →
Office / nonfacility
Unavailable
Facility
$962.25
Virginia →
Office / nonfacility
Unavailable
Facility
$851.02
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43420 billing questions
How does 43420 differ from 43425?
The approach determines the choice: 43420 is for a cervical repair, while 43425 is for a thoracic repair. The operative report should support the route used.
When should an esophageal wound repair code be considered instead?
Use the wound-repair code family when repairing an esophageal wound or injury. 43420 describes repair of an esophageal opening through a cervical approach.
What documentation supports reporting 43420?
Document the esophageal defect or opening, the cervical approach, and the repair performed. The operative report should make clear whether the service was repair of an opening rather than repair of a wound or injury.
Can modifier 50 be reported?
No. Modifier 50 is inappropriate for this esophageal repair.
How is 43420 handled when other procedures occur in the same session?
CMS pays the highest-valued procedure in full and applies the standard multiple-procedure reduction to the other procedures. The 90-day global period includes the day-before preoperative visit and related postoperative care.
What documentation is needed for assistant or co-surgeon payment?
Assistant-at-surgery payment requires documentation of medical necessity. Co-surgeon payment requires supporting documentation; team-surgery payment is 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.
5,2454340F,,Cnslng chldbrng women epi,M,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00
5,24643410,,Repair esophagus wound,A,,16.00,8.67,NA,8.67,,2.34,27.01,27.01,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,24743415,,Repair esophagus wound,A,,43.76,17.52,NA,17.52,,11.01,72.29,72.29,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,24843420,,Repair esophagus opening,A,,16.36,7.56,NA,7.56,,2.39,26.31,26.31,0,090,0.09,0.81,0.10,2,0,0,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,24943425,,Repair esophagus opening,A,,24.41,10.62,NA,10.62,,6.16,41.19,41.19,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,25043450,,Dilate esophagus 1/mult pass,A,,1.25,4.95,,0.79,,0.15,6.35,2.19,0,000,0.00,0.00,0.00,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,25143453,,Dilate esophagus,A,,1.37,23.35,,0.77,,0.18,24.90,2.32,0,000,0.00,0.00,0.00,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00