CPT code 43242: EUS-guided biopsy2026 Medicare rate & RVUs in Washington
Report this service when upper endoscopy with endoscopic ultrasound guides needle aspiration or biopsy of a lesion in or beyond the gastrointestinal wall.
CMS doesn’t publish an office rate for 43242 in Washington.
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 43242 covers
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.
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 43242 pays more and less in Washington
| Payment locality | Office | Facility |
|---|---|---|
| Rest Of Washington | Unavailable | $231.04 |
| Seattle (King Cnty) | Unavailable | $248.00 |
How the 43242 rate is calculated
Each of 43242’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 · 43242
RVUs × geographic indexes × conversion factor
Work4.61
4.61 RVUs× 1.000 GPCI
Practice expense1.78
1.78 RVUs× 1.000 GPCI
Malpractice0.49
0.49 RVUs× 1.000 GPCI
Adjusted RVUs
6.8800
Conversion factor
$33.4009
Medicare rate
$229.80
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 43242
The CMS indicators that decide how 43242 is paid alongside other services.
CMS payment indicators · 43242
EUS-guided biopsy
| 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
43242 without 51 · national facility
$229.80
EUS-guided biopsy
43242-51 · Second procedure: 50%
$114.90
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%).
43242 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 43238EUS-guided biopsy
- Both involve EUS-guided needle sampling. Distinguish 43242's intramural or transmural sampling service and included examination from 43238's transmural sampling criteria.
- 43237Endoscopic ultrasound
- 43237 describes diagnostic EUS without needle sampling; 43242 requires EUS-guided aspiration or biopsy.
- 43239EGD with biopsy
- 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.
- 43232Esophageal EUS
- 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.
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 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
Show the CMS file lines behind this rate
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