Summary & Overview
CPT 43255: EGD (Upper Endoscopy) with Endoscopic Hemostasis
CPT code 43255 identifies an esophagogastroduodenoscopy (EGD) performed with a flexible endoscope through the mouth in which the clinician provides endoscopic hemostasis to stop active bleeding. This code captures combined diagnostic visualization of the esophagus, stomach, and duodenum with a therapeutic intervention to control hemorrhage, making it clinically significant for acute GI bleeding management and for hospital and outpatient endoscopy services.
Key national payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for use of 43255, the typical settings where the service is delivered, and the relevance of the code for billing for therapeutic upper endoscopy encounters. The publication outlines expected service characteristics, common modifiers associated with endoscopic procedures (listed separately), and where to find related coding guidance.
The report is intended to inform clinicians, billing staff, and policy analysts about the role of CPT code 43255 in managing upper GI bleeding, operational implications for endoscopy units, and the coding elements to consider when documenting combined diagnostic and therapeutic endoscopic procedures. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 43255 describes an esophagogastroduodenoscopy (EGD) performed with a flexible endoscope passed through the mouth to visualize the esophagus, stomach, and duodenum. During this procedure, the provider performs active hemostasis to stop patient bleeding.
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Service type: Diagnostic and therapeutic upper endoscopy with endoscopic hemostasis
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Typical site of service: Endoscopy suite or hospital outpatient department
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Clinical & Coding Specifications
Clinical Context
A 58-year-old male presents to the outpatient endoscopy unit with melena and symptomatic iron-deficiency anemia. After initial evaluation in the clinic, the gastroenterologist schedules an esophagogastroduodenoscopy to identify the bleeding source. The patient arrives fasting, undergoes pre-procedure assessment and informed consent, and receives moderate sedation administered by anesthesia personnel per facility policy. During the flexible endoscopic examination of the esophagus, stomach, and duodenum via the oral route, an actively bleeding gastric ulcer is identified. The endoscopist achieves hemostasis using endoscopic clips and injection therapy. The procedure concludes with post-procedure recovery monitoring and documentation of findings, interventions, and recommended follow-up.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When billing only the physician’s interpretive or procedural work and the facility bills technical component separately |
52 | Reduced services | When the procedure is partially reduced or not completed for documented clinical reasons |