Summary & Overview

CPT 43250: EGD with Removal of Mass(es) (Polypectomy/Excisional Biopsy)

CPT code 43250 denotes an esophagogastroduodenoscopy (EGD) with removal of one or more abnormal masses or growths via grasping, excision, and cauterization, with specimens submitted for laboratory analysis. This code captures a commonly performed diagnostic and therapeutic upper endoscopy procedure that integrates tissue removal during visualization of the esophagus, stomach, and duodenum. Nationally, EGD with tissue removal is a core procedure in gastroenterology and surgical practice due to its role in diagnosing and treating mucosal lesions, neoplasia, and symptomatic polyps.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context and service settings, plus benchmarking and policy considerations where available. The content summarizes service definitions, typical sites of service, common modifiers, and avenues for documentation and coding clarity. It also outlines what to expect in terms of clinical workflow: diagnostic visualization, therapeutic excision, and specimen submission for pathology.

This publication is designed to inform billing staff, clinicians, and revenue-cycle professionals about the clinical and coding scope of 43250, clarifying the procedure’s intent and operational setting. Data not available in the input is noted where applicable; the focus remains on clear, actionable definition and context rather than payer-specific reimbursement guidance.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare43250CPTesophagogastroduodenoscopyEGDpolypectomyendoscopygastroenterologyoutpatient-surgery

Billing Code Overview

CPT code 43250 describes an esophagogastroduodenoscopy (EGD) with removal of one or more abnormal masses or growths using a flexible esophagogastroduodenoscope inserted through the mouth. The procedure involves visualization of the esophagus, stomach, and proximal small intestine (duodenum) with a tubular instrument that contains a light source and camera, and removal of tissues by an instrument that grasps, excises, and cauterizes the lesion. Specimens removed during the procedure are sent to a laboratory for analysis.

Service type: Endoscopic diagnostic and therapeutic procedure (EGD with polypectomy or excisional biopsy)

Typical site of service: Hospital outpatient department, ambulatory surgery center, or endoscopy suite

Clinical & Coding Specifications

Clinical Context

A 58-year-old patient with a history of chronic gastroesophageal reflux disease and recent onset of progressive dysphagia is referred for diagnostic and therapeutic upper endoscopy. The provider obtains informed consent and performs sedation in an outpatient endoscopy suite or ambulatory surgical center. A flexible esophagogastroduodenoscope is introduced orally to inspect the esophagus, stomach, and duodenum. During inspection, a 1.2 cm sessile polyp in the antrum is identified. The provider uses a hot snare to grasp, excise, and cauterize the lesion, retrieves the specimen, and submits it to pathology. The patient is recovered from sedation in the PACU and discharged with post-procedure instructions and pathology follow-up. Typical sites of service include the outpatient endoscopy unit, ambulatory surgery center, or hospital endoscopy suite. The service type is diagnostic and therapeutic endoscopy with polypectomy and specimen retrieval for histopathologic analysis.

Coding Specifications

Modifier	Description	When to Use
`00`	No modifier; standard reporting	Use when no additional modifier applies.
`22`	Increased procedural services	Use when work or complexity substantially exceeds typical for `43250`.
`23`	Unusual anesthesia	Use if procedure performed under general anesthesia when local/regional/sedation would ordinarily be used.
`26`	Professional component	Use when billing only the professional component of a service (rare for endoscopy when facility bills technical component).
`52`	Reduced services	Use when the procedure is partially reduced or not fully completed.
`53`	Discontinued procedure	Use when procedure is started but terminated due to extenuating circumstances.
`59`	Distinct procedural service	Use to indicate a distinct endoscopic procedure separate from another service on the same day.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons.
`73`	Discontinued outpatient hospital/ASC procedure prior to anesthesia induction	Use when the outpatient endoscopic procedure is cancelled after patient preparation but before anesthesia.
`78`	Unplanned return to OR/procedure following initial procedure	Use when patient returns for related procedure during global period for a complication.
`80`	Assistant surgeon	Use when an assistant surgeon participates.
`99`	Data not used — placeholder	Data not available in the input.

Taxonomy Code	Specialty	Notes
`207K00000X`	Gastroenterology	Most common specialty performing diagnostic and therapeutic EGD with polypectomy.
`207L00000X`	Gastrointestinal Endoscopy	Endoscopists who focus on therapeutic endoscopic procedures.
`208000000X`	General Surgery	Surgeons who perform endoscopy in surgical settings.
`333600000X`	Anesthesiology	Provides monitored anesthesia care or general anesthesia for endoscopic procedures.
`103T00000X`	Internal Medicine	Hospitalist or internist may perform or assist in endoscopic procedures in some settings.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K21.9`	Gastroesophageal reflux disease without esophagitis	Common indication for EGD to evaluate chronic reflux or dysphagia.
`K22.8`	Other specified diseases of esophagus	Used for atypical esophageal lesions or symptoms prompting EGD.
`K31.89`	Other specified diseases of stomach and duodenum	Applies to non-specific gastric lesions or symptoms leading to endoscopy and polypectomy.
`K31.7`	Gastrointestinal polyps	Directly relevant when polyps are identified and removed during EGD.
`R13.10`	Dysphagia, unspecified	Common presenting symptom prompting diagnostic EGD.
`R19.4`	Change in bowel habit	Less specific but may be coded when upper GI pathology suspected; included as possible related symptom.
`D37.4`	Neoplasm of uncertain behavior of stomach	Used when lesion pathology is uncertain and removed for diagnosis.
`C16.9`	Malignant neoplasm of stomach, unspecified	Relevant when biopsy or polypectomy is performed for known or suspected malignancy; directs therapeutic/diagnostic intent.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`43235`	Esophagogastroduodenoscopy, flexible, transoral; diagnostic, with or without collection of specimen(s) by brushing or washing	Often billed when diagnostic EGD is performed without therapeutic excision; may be listed if no polypectomy is performed.
`43239`	Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple	Billed when mucosal biopsies are obtained rather than when a polyp is snared and removed; may accompany `43250` if additional biopsies are taken.
`43251`	Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps	Alternative technique code for polypectomy when hot biopsy forceps used instead of snare.
`43255`	Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method	Performed if hemostasis is required during or after polypectomy.
`43248`	Placement of endoscopic stent in esophagus, stomach, or duodenum (separate code)	May be performed in the same session if obstructing lesion requires stenting, though this is a distinct therapeutic intervention.