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2025 CPT code 43216

Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery.

Refer to CPT coding guidelines and any relevant payer-specific guidelines.

Modifiers such as 22 (increased procedural services), 51 (multiple procedures), 59 (distinct procedural service), and others may be applicable depending on the circumstances. Ensure documentation supports the use of any modifier.

Medical necessity must be established for this procedure. This is typically done by documenting symptoms, diagnostic findings (e.g., abnormal barium swallow, positive biopsy), or other clinical evidence that supports the need for the procedure.The medical necessity should align with payer guidelines.

The physician is responsible for preparing and anesthetizing the patient, inserting and maneuvering the esophagoscope, visually inspecting the esophagus, removing the lesion(s) with hot biopsy forceps or bipolar cautery, ensuring hemostasis, and submitting specimens for lab analysis.

IMPORTANT Do not report 43216 in conjunction with 43197, 43198, 43200. If a snare technique is used for removal, use 43217.A separate biopsy (43202) in the same area is not reported as it is included. Biopsy of a separate, unrelated area may be reported with modifier 59.

In simple words: The doctor examines your esophagus (the tube connecting your throat to your stomach) using a thin, flexible tube with a camera and light. If they find any abnormal growths, they will remove them using a special heated tool to minimize bleeding. The removed tissue is then sent to a lab for testing.

This code describes a procedure where a physician examines the esophagus using a flexible esophagoscope inserted through the mouth. During the procedure, any tumors, polyps, or other lesions found are removed using hot biopsy forceps or bipolar cautery.The removed specimens are then sent to a laboratory for analysis.

Example 1: A patient presents with difficulty swallowing.An esophagoscopy reveals a small polyp in the mid-esophagus. The polyp is removed using hot biopsy forceps during the procedure., During a routine upper endoscopy, a small tumor is discovered in the distal esophagus. Using a flexible esophagoscope, the physician removes the tumor with bipolar cautery., A patient with Barrett's esophagus undergoes surveillance esophagoscopy.Several areas of dysplasia are identified and removed with hot biopsy forceps for further evaluation.

Documentation should include the following: indication for the procedure, size and location of the lesion(s), method of removal (hot biopsy forceps or bipolar cautery), number of lesions removed, and confirmation that specimens were sent for pathological analysis.If a biopsy is performed in a separate location, documentation needs to justify its distinct nature.

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