Summary & Overview
CPT 43245: EGD with Dilation of Gastric or Duodenal Stricture
CPT code 43245 represents endoscopic dilation of gastric and/or duodenal strictures performed via a flexible endoscope passed through the mouth into the esophagus, stomach, and duodenum. This therapeutic esophagogastroduodenoscopy (EGD) with dilation addresses luminal narrowing that can cause obstruction, pain, or impaired nutrition. Nationally, this procedure is an important component of gastroenterology services for benign and postsurgical strictures and has implications for access to specialty care, facility utilization, and procedure coding accuracy.
Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for the procedure, common sites of service where it is performed, and the coding definition. The publication also summarizes benchmarking considerations, typical billing modifiers used with therapeutic endoscopy (listed separately), and policy updates that affect coverage and documentation requirements. Practical insights cover coding specificity, claim submission factors that commonly trigger review, and the clinical scenarios in which dilation is typically indicated.
Data not available in the input includes insurer-specific reimbursement rates, associated taxonomies, and ICD-10 diagnosis codes tied to individual claims. The content is presented for a national audience and focuses on clinical and coding clarity rather than individualized payer instructions.
Billing Code Overview
CPT code 43245 describes a procedure in which a provider inserts a flexible endoscope through the mouth and advances it into the esophagus, stomach, and duodenum to dilate one or more gastric and/or duodenal strictures. This procedure is a therapeutic upper gastrointestinal endoscopy with dilation.
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Service type: Endoscopic therapeutic procedure (esophagogastroduodenoscopy with dilation)
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Typical site of service: Hospital outpatient department or ambulatory surgical center; may also be performed in an endoscopy suite within a clinic setting
Clinical & Coding Specifications
Clinical Context
A 64-year-old patient with a history of peptic ulcer disease and progressive postprandial vomiting presents with weight loss and evidence of gastric outlet obstruction on imaging. The gastroenterology team schedules an upper endoscopy with dilation to evaluate and treat suspected benign gastric or duodenal strictures. In the endoscopy suite, after informed consent and conscious sedation provided by anesthesia or the proceduralist, a flexible endoscope is introduced orally and advanced through the esophagus and stomach into the duodenum. The strictured segment(s) are identified visually and with fluoroscopic assistance as needed. Through-the-scope balloon or bougie dilators are used to gradually dilate one or more gastric and/or duodenal strictures to restore luminal patency. Immediate complications are monitored, including bleeding or perforation; post-procedure instructions include diet progression and signs of potential complications. Billing reflects diagnostic endoscopy with therapeutic dilation per 43245 when dilation of gastric and/or duodenal strictures is performed during the same session.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work or time substantially exceeds typical for 43245 and documentation supports additional work. |