Summary & Overview

CPT 43242: EUS-Guided Fine Needle Aspiration/Biopsy of Upper GI

CPT code 43242 denotes endoscopic ultrasound-guided fine needle aspiration or biopsy (EUS-FNA/FNB) performed via a flexible upper endoscope advanced through the mouth into the esophagus, stomach, and duodenum, with sampling of the upper GI tract wall or jejunum distal to a surgically altered stomach. This procedure is an important diagnostic tool for evaluating submucosal lesions, pancreatic and peri-intestinal masses, and for staging or diagnosing malignancy and other focal pathology in the upper gastrointestinal tract.

Key national payers in scope include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find: concise clinical context for when CPT code 43242 is used, expected sites of service, and typical clinical indications; a summary of the payer landscape covered in the analysis; plus coverage and billing considerations relevant to hospital-based and ambulatory settings. The publication also highlights benchmarking topics and policy changes that affect utilization and coding practice nationally. Data not provided in the input — such as associated taxonomies, ICD-10 diagnosis mappings, and payer-specific reimbursement rates — are identified as unavailable where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare43242CPTendoscopic ultrasoundEUS-FNAupper gastrointestinalendoscopybiopsygastroenterology

Billing Code Overview

CPT code 43242 describes a diagnostic and tissue-sampling procedure in which the provider inserts a flexible endoscope through the mouth and advances it into the esophagus, stomach, and duodenum. Under endoscopic ultrasound guidance, the clinician performs a fine needle aspiration or biopsy of lesions in or through the wall of the upper gastrointestinal tract or of the jejunum distal to an anastomosis from a surgically altered stomach.

Service type: Endoscopic ultrasound-guided fine needle aspiration or biopsy of the upper gastrointestinal tract (EUS-FNA/FNB)
Typical site of service: Hospital endoscopy suite, ambulatory surgery center, or outpatient endoscopy unit

Clinical & Coding Specifications

Clinical Context

A 62-year-old male with a history of chronic alcohol use and recent weight loss presents with progressive dysphagia and an upper abdominal mass on CT. The gastroenterologist schedules an esophagogastroduodenoscopy with endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to sample a submucosal lesion in the gastric wall and an adjacent perigastric lymph node. The patient arrives to an ambulatory endoscopy suite after routine pre-procedure assessment, informed consent, and moderate sedation administered by anesthesia staff or the endoscopy team. During the procedure the provider advances a flexible endoscope through the mouth into the esophagus, stomach, and duodenum. Under endoscopic ultrasound guidance the physician performs targeted FNA/biopsy of the gastric lesion and a separate aspirate of a perigastric lymph node. Post-procedure the patient is observed in recovery until discharge criteria are met or admitted if complications occur. Specimens are sent to pathology with appropriate labeling and documentation of sites and number of passes. Billing captures the primary service as 43242, with modifier and diagnosis linkage as indicated by payer rules.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	When reporting only the physician’s interpretation component separate from technical services provided by the facility or hospital (rare for endoscopy procedures billed by performing physician).
`50`	Bilateral procedure	Not typically applicable to `43242` but used if payer requires bilateral indicator for paired organ procedures (generally not used for upper GI EUS-FNA).
`51`	Multiple procedures	When `43242` is reported on the same date with other distinct procedures; used per payer rules to indicate multiple procedures.
`52`	Reduced services	When the full extent of `43242` is not performed (e.g., aborted due to poor visualization) and the service is reduced but not discontinued.
`53`	Discontinued procedure	When `43242` is started but discontinued due to patient instability or unexpected findings prior to completion.
`59`	Distinct procedural service	When `43242` is performed at a separate site or is distinct from another procedure on the same date (e.g., separate diagnostic endoscopic interventions).
`62`	Two surgeons	When two surgeons work together as primary surgeons (rare for endoscopy but applicable if two physicians are performing shared operative roles).
`76`	Repeat procedure by same physician	When the same physician repeats `43242` within the global period because it was necessary due to technical failure (note: `76` is not in the provided list and thus omitted).
`78`	Unplanned return to the operating/procedure room	When a return to the procedure room for related care occurs during the global period for a complication of `43242`.
`79`	Unrelated procedure or service by the same physician during the global period	When an unrelated procedure is performed during the global period for a different condition (note: `79` is not in the provided list and thus omitted).
`62`	(duplicate)	(duplicate entry removed)

Taxonomy Code	Specialty	Notes
2086S0001X	Gastroenterology	Physicians who perform diagnostic and therapeutic upper endoscopy and endoscopic ultrasound.
207P00000X	General Surgery	Surgeons trained in upper GI endoscopy and EUS in some practices.
207RG0100X	Internal Medicine	Hospital-based internists or proceduralists who may perform endoscopy in select settings.
363LF0000X	Anesthesiology	Provides sedation/anesthesia services during `43242` when billed separately.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C16.9`	Malignant neoplasm of stomach, unspecified	Gastric mass or suspected gastric cancer often requires EUS-FNA for tissue diagnosis and staging.
`C15.9`	Malignant neoplasm of esophagus, unspecified	Suspected esophageal malignancy with submucosal invasion may need EUS-guided sampling for diagnosis and staging.
`K31.84`	Gastrointestinal stromal tumor (GIST)	Subepithelial gastric or duodenal lesions suspicious for GIST are commonly sampled with EUS-FNA.
`K31.89`	Other diseases of stomach and duodenum	Includes submucosal or cystic lesions requiring EUS evaluation and biopsy.
`R10.9`	Unspecified abdominal pain	When workup for persistent upper abdominal pain reveals a suspicious lesion, EUS-FNA may be performed for diagnosis.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`43242`	Esophagogastroduodenoscopy, flexible, transoral; with EUS-guided FNA/biopsy of lesion of the upper GI tract or jejunum distal to surgically altered stomach	Primary procedure described.
`43239`	Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound, diagnostic	Often performed when additional ultrasound evaluation of lesions is needed without FNA; may be performed in same session when imaging only is required.
`43245`	Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound, with biopsy, single or multiple	Billed when EUS with tissue sampling is performed via forceps or through-the-scope biopsy rather than FNA; may be used if sampling technique differs.
`43235`	Esophagogastroduodenoscopy, flexible, transoral; diagnostic, with or without collection of specimen(s) by brushing or washing	Performed when initial diagnostic EGD is done without EUS; may precede or follow EUS-FNA for mucosal evaluation.
`43246`	Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound, with FNA/biopsy of other lesion(s)	Used for additional or separate EUS-guided sampling of lesions in different anatomic locations beyond the primary site; may be reported when multiple distinct EUS-FNA sites are sampled.