Endoscopies of the gastrointestinal tract (GIT) are among the most commonly performed procedures in gastroenterology. CPT code 43248 is an important endoscopy code used to bill a specific type of endoscopic procedure. So, accurate billing matters.
Yet, many 43248-related insurance claims are denied. The reason? Errors while billing and the inappropriate use of CPT code 43248. That is why billing experts at MediBillMD have created this comprehensive guide on code 43248.
In this blog, we will discuss how you can effectively code endoscopies using code 43248, the modifiers you can append, and billing best practices to optimize your collections. So, let’s start.
CPT Code 43248 – Description
CPT code 43248 is a gastroenterology billing code. The official definition of 43248 provided by the American Medical Association (AMA) defines it as:
“Esophagogastroduodenoscopy (EGD), flexible, transoral; with insertion of guidewire followed by passage of dilator(s) through esophagus over the guidewire.”
Sounds confusing, right? Let’s break this down into simpler terms.
CPT code 43248 is used for the billing of a therapeutic endoscopic procedure. In this procedure, a healthcare provider inserts a flexible endoscope through the patient’s mouth and down into the esophagus, stomach, and duodenum. The “guidewire” and “dilation” parts indicate a therapeutic step: widening a narrowed section of the esophagus to improve swallowing.
The guidewire ensures precise placement of the dilating tool, which is either a balloon or a mechanical dilator. EGD is a safe procedure and is frequently used by gastroenterologists.
Scenarios Where CPT Code 43248 is Applicable
CPT code 43248 can be used in several situations. Typically, it is used when a patient requires both diagnostic evaluation and esophageal dilation in a single session. But that is not a fixed rule, and other situations might also require 43248 for billing. The following are some real-world scenarios in which it can be used:
Esophageal Strictures
Esophageal stricture means the narrowing of the esophagus. It may be due to:
- Gastroesophageal reflux disease (GERD)
- Prior radiation therapy
- Caustic ingestion
- Post-surgical scarring
- Eosinophilic esophagitis
Schatzki Ring
A benign ring of tissue in the lower esophagus can intermittently block food. In this case, the doctor might use EGD for dilation and to provide relief.
Applicable Modifiers for CPT Code 43248
You may append the following modifiers to CPT code 43248 for enhanced coding specificity and accurate reimbursement.
| Modifier | Description | Use Case |
|---|---|---|
| 22 | Increased Procedural Services | Apply this if the procedure is unusually complex or time-intensive. |
| 51 | Multiple Procedures | Indicates that 43248 is one of several procedures performed in the same session. |
| 59 | Distinct Procedural Service | Use this when the procedure is separate from other services performed on the same day, like a biopsy at a different site. |
CPT Code 43248 – Billing & Reimbursement Guidelines
Follow these billing best practices to avoid code 43248-related claim denials.
Follow Documentation Requirements
Documentation is the most important part of filing insurance claims. It is essential for supporting medical necessity. For CPT code 43248, the following documents are important:
- Patient’s symptoms, history, and the indication for the procedure
- Method of sedation used
- Findings during the initial endoscopic examination
- The technique used for guidewire placement
- Size and type of dilator(s) used
- Number of dilations performed
- Post-dilation assessment of the treated area
- Instructions provided to the patient, follow-up recommendations, and any complications
Pair with the Correct ICD-10 Diagnosis Codes
To establish the medical necessity of CPT code 43248, pair the code with the recommended ICD-10 codes. Some frequently used ICD-10 codes to support EGD with guidewire insertion are:
- K20.80: Other esophagitis without bleeding
- K20.81: Other esophagitis with bleeding
- K21.00: Gastro-esophageal reflux disease with esophagitis, without bleeding
- K21.01: Gastro-esophageal reflux disease with esophagitis, with bleeding
- K22.0: Achalasia of the cardia
- K22.2: Esophageal obstruction
- K22.4: Dyskinesia of the esophagus
- K22.10: Ulcer of the esophagus without bleeding
- K22.11: Ulcer of the esophagus with bleeding
- R13.10: Dysphagia, unspecified
- R13.19: Other dysphagia
Medicare Reimbursement Rates
According to the latest Medicare Physician Fee Schedule, the national average Medicare
reimbursement rates for CPT code 43248 are:
- Facility setting (hospital outpatient/ASC): $160.77
- Non-facility setting (office): $405.37
For the facility itself, the 2025 Medicare reimbursement rates are:
- Ambulatory Surgery Center payment: $470.24
- Hospital Outpatient payment: $864.59
However, please note that these rates are subject to geographic adjustments based on practice location and may be affected by sequestration and other legislative changes. Plus, according to Medicare’s Procedure Price Lookup tool, the average patient payment in 2025 is approximately $131 in an Ambulatory Surgery Center and $218 in a Hospital Outpatient Department.
Wrapping Up
So, there you have it, the complete description of CPT code 43248. Let’s recap everything briefly. CPT code 43248 represents a specific therapeutic endoscopic procedure involving guidewire-assisted esophageal dilation. For proper reimbursement, you must append the right documents with your claim and make sure to use the appropriate ICD-10 diagnosis code.
If you are still facing issues with medical coding or want to outsource your non-clinical operations, consider acquiring premium gastroenterology billing services from professionals at MediBillMD.
