43239
Upper Gastrointestinal Endoscopy With Biopsy
Code Description
CPT code 43239 is used to report an upper gastrointestinal endoscopy (EGD) performed with biopsy. During the procedure, a flexible endoscope is inserted through the mouth to examine the esophagus, stomach, and duodenum while obtaining tissue samples for diagnostic evaluation.
The procedure is commonly performed to investigate gastrointestinal symptoms, evaluate abnormalities seen on imaging, and diagnose conditions affecting the upper digestive tract.
When to Use 43239
Common examples include:
persistent acid reflux
stomach ulcers
abnormal upper GI imaging
gastrointestinal bleeding
suspected Barrett's esophagus
evaluation of stomach or esophageal lesions
Documentation Requirements
Documentation should include:
indication for the procedure
anatomical areas examined
biopsy location
tissue samples obtained
procedural findings
patient tolerance
Common Billing Mistakes
Common billing mistakes include:
reporting a diagnostic endoscopy code instead of biopsy code
failure to document biopsy collection
insufficient procedural findings
incorrect anatomical documentation
incomplete operative reports
Related CPT Codes
43235
Diagnostic Upper GI Endoscopy
43248
Upper GI Endoscopy With Dilation
43249
Upper GI Endoscopy With Balloon Dilation
FAQ
What is the difference between CPT 43235 and 43239?
CPT 43235 is a diagnostic upper endoscopy without tissue sampling, while CPT 43239 includes obtaining a biopsy during the procedure.
What areas are examined during an upper GI endoscopy?
The esophagus, stomach, and duodenum are typically examined.
Why is a biopsy performed during an endoscopy?
A biopsy allows tissue samples to be evaluated for inflammation, infection, cancer, and other gastrointestinal conditions.
Is CPT 43239 considered a surgical procedure?
Yes. CPT 43239 is classified within the Surgery section of the CPT code set under Digestive System procedures.
Procedure Type
Upper GI Endoscopy
Body Area
Technique
Esophagus, Stomach, and Duodenum
Endoscopy With Biopsy
