2025 CPT code 43243
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Esophagogastroduodenoscopy (EGD) with injection sclerosis of esophageal or gastric varices.
Modifiers 52 (Reduced Services) and 53 (Discontinued Procedure) may apply. Other modifiers may apply depending on the circumstances of the procedure.
Medical necessity for 43243 is established when a patient presents with active upper GI bleeding from varices or there is a high risk of bleeding from varices.This risk is often assessed based on the size and location of the varices, the patient's underlying liver disease, and overall clinical status. Prophylactic sclerotherapy may be medically necessary in high-risk patients to prevent first-time bleeding episodes.
The physician is responsible for performing the esophagogastroduodenoscopy, identifying varices, and administering the sclerosing injections.Pre-procedure assessment, anesthesia administration (if applicable), post-procedure monitoring, and interpretation of results are also part of the physician's responsibility.
In simple words: The doctor inserts a thin, flexible tube with a camera (endoscope) down your throat to look at your esophagus (the tube connecting your mouth and stomach), stomach, and the beginning of your small intestine. If they find enlarged blood vessels (varices) that are bleeding or likely to bleed, they inject a special solution to seal them and stop the bleeding.
This CPT code describes a flexible, transoral esophagogastroduodenoscopy (EGD) procedure where a flexible endoscope is inserted through the mouth into the esophagus, stomach, and duodenum.During the procedure, injection sclerotherapy is performed to treat esophageal and/or gastric varices (enlarged blood vessels) by injecting a sclerosing solution to cause the vessel walls to adhere, thus preventing bleeding.The procedure is typically performed for diagnostic and therapeutic purposes to address variceal bleeding. Note that code 43243 should not be reported with 43236, 43255 for the same lesion, nor with 43197, 43198, 43235, 44360-44379.
Example 1: A patient presents with hematemesis (vomiting blood) and melena (dark, tarry stools) suggesting upper gastrointestinal bleeding.EGD with injection sclerotherapy (43243) is performed to identify and treat the source of bleeding, which is found to be esophageal varices., A patient with a history of cirrhosis and portal hypertension undergoes a routine EGD to screen for esophageal varices.During the procedure, small varices are identified, and injection sclerotherapy is performed prophylactically (43243) to reduce the risk of future bleeding., A patient with known esophageal varices experiences a sudden episode of hematemesis.Emergency EGD with injection sclerotherapy (43243) is performed to control the acute bleeding.
Complete patient history including symptoms (e.g., bleeding, dysphagia), relevant past medical history (e.g., cirrhosis, portal hypertension), physical examination findings, endoscopy report detailing the location and number of varices treated, type and amount of sclerosant used, and post-procedure assessment.Imaging studies (e.g., ultrasound) to assess the liver may also be required for appropriate medical necessity documentation.
** Accurate coding requires careful review of the operative report to ensure that the procedure performed matches the selected code.The use of modifier 52 or 53 requires appropriate documentation.
- Revenue Code: P8B (ENDOSCOPY - UPPER GASTROINTESTINAL)
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Gastroenterology, Hepatology
- Place of Service:Office, Hospital (Inpatient and Outpatient), Ambulatory Surgical Center