CPT 43235 Coding Rules, Modifiers, and NCCI

Last Updated on August 28, 2025

There are days when 43235 is the quiet hero, clean, diagnostic, brush/wash if needed, done. Other days it’s a trap door into denials. This blog shows the judgment calls that separate clean claims from headaches, with the exact documentation lines that keep auditors happy.

What CPT 43235 really is

CPT 43235 reports a flexible, trans-oral diagnostic EGD, examining the esophagus, stomach, and typically the second part of the duodenum. You can collect specimens by brushing or washing and still report 43235, as long as no tissue is removed and no therapeutic work is performed. For GI-specific workflows, explore our gastroenterology billing services.

Do not use 43235 if any of the following occur in the same session:

• Biopsy taken → report 43239.
• Therapy performed (e.g., bleeding control 43255, dilation 43249, foreign body 43247).
• EUS performed → use 43237–43242 as appropriate.

Core rule to remember: Surgical endoscopy includes diagnostic endoscopy. If a more extensive upper-GI endoscopic service is performed, report only the single most comprehensive code, never stack 43235 with another EGD family code.

Real-world scenarios with CPT Code 43235

These are the patterns coders see most. Each case outlines the correct code, the NCCI logic that prevents unbundling, the LCD cues that prove necessity, and the exact documentation to include. If the work changes, we point to the right endoscopy code so you do not stack or overcode.

Casefile #1 — Anemia workup with brushings, no tissue removed

Scenario: Iron-deficiency anemia with melena. Endoscopist advances to D2, documents segmental findings, and takes brushings only. No biopsy or therapy.

Code: 43235 (diagnostic EGD).
Why it pays: Brush/wash is included in 43235. Anchor medical necessity to your MAC’s LCD for Upper-GI Endoscopy and state the extent reached.

Audit-friendly note lines: “EGD (diagnostic). Indication: melena with iron-deficiency anemia (meets LCD criteria). Extent: to D2. Specimens: brushings only; no biopsy/therapy. Post-procedure: stable.”

Sedation check:

• Medicare: if the same physician/QHP provides moderate sedation, report G0500 (first 15 min) + 99153 (each additional 15). Document intra-service time and an independent trained observer.
• Commercial: typically 99152/99153 when moderate sedation is by the same physician/QHP.
• If an anesthesia professional provides deep sedation/GA, bill anesthesia codes per payer policy.

Casefile #2 — Planned diagnostic, then you took a bite

Scenario: Dysphagia evaluation. Mucosal abnormality → biopsy taken.

Code: 43239 only.
Why: The moment tissue is removed, the diagnostic service is bundled into the surgical endoscopy. Reporting 43235 + 43239 will trigger edits.

Same-day E/M? Bill only if the visit is significant & separately identifiable beyond the usual pre/post work of a minor procedure—then append modifier 25. Avoid auto-adding it.

Casefile #3 — Tight stricture; incomplete exam

Scenario: Severe narrowing stops the scope before reaching the duodenum; no therapy performed.

Code: 43235-52 (reduced service) or 43235-53 (discontinued), depending on whether the endoscopy began and why it stopped. Be explicit.

Example wording:

• “EGD reduced due to critical stricture; unable to reach D2. No therapy.”
• “Procedure discontinued post-induction because of hypoxia.”
  

Modifiers for CPT 43235

Use modifiers sparingly and only when the record clearly supports them. For 43235, these are the few that legitimately apply, and the ones that do not.

Commonly used Modifiers

Modifier 25 – Significant, separately identifiable E/M, same day
Use only when a same-day visit goes beyond the usual pre and post work of a minor procedure and is clearly documented as a distinct service.
Documentation cue: Separate HPI/Exam/MDM tied to a different problem or a materially expanded decision process.

Modifier 52 – Reduced services
Use when the diagnostic EGD was performed but not to the full extent described (for example, unable to reach D2 due to critical stricture) and no more extensive endoscopic service was done.
Note line: “EGD reduced due to severe stricture; unable to reach D2. No therapy performed.”

Modifier 53 – Discontinued procedure
Use when the procedure was terminated after anesthesia or scope start due to extenuating circumstances or patient safety, and the full diagnostic service was not completed.
Note line: “Procedure discontinued after induction due to hypoxia; scope withdrawn; patient stabilized.”

Misused Modifiers with CPT 43235

Modifier 59 or X modifiers – Do not append 59 to unbundle 43235 from other upper-GI endoscopy codes in the same session. Surgical endoscopy includes diagnostic; report the single most comprehensive code.

Modifier 26 or TC – Not appropriate, 43235 is a surgical endoscopy code, not a service with professional/technical splits like imaging.

Modifier 51 – Unnecessary for most payers and not a workaround for endoscopy family bundling. It does not convert 43235 into a separately payable add-on.

Modifiers 76/77 – “Repeat procedure” modifiers are rarely appropriate for 43235. Repeating the same endoscopic service in the same anatomic region during the same session is generally one unit only.

NCCI and LCD Guidelines for CPT 42325

1) NCCI fine print that matters

• One code per session: choose the most comprehensive upper-GI endoscopy performed.
• Integral services such as venous access, routine infusions/injections, pulse oximetry, and anesthesia provided by the surgeon/QHP are not separately reportable with an endoscopy.
• Same-day E/M: permissible with modifier 25 only when truly significant & separately identifiable.

2) LCD reality (medical necessity)

Use your MAC’s LCD for Upper-GI Endoscopy (e.g., L35350) to frame indications (GI bleeding, alarm symptoms, dysphagia/odynophagia, abnormal imaging, etc.). Mirror LCD language for indication, always document extent reached, segmental findings, what was and wasn’t done (e.g., “brush/wash only; no biopsy/therapy”), sedation details, and post-procedure status.

one-minute checks that prevent denials

• Any tissue removed? Yes → 43239 (don’t stack with 43235).
• Sedation coded by payer? Medicare: G0500 (+99153). Commercial: 99152/99153. Note time + independent observer for Medicare.
• Integral services appearing separately? Clean them off the claim per NCCI.
• Units right? Most Part B endoscopies are 1 unit per date under MUE—verify the current Practitioner MUE table/MAC lookup.
• Follow payerwise coding guidelines for maximum reimbursement

2025 reimbursement

Skip static dollar amounts. Pull current, locality-specific rates from the CMS Physician Fee Schedule Look-Up Tool (professional component). Context: CY 2025 conversion factor = $32.35 (-2.83% vs 2024). Multiply CF × total RVUs for the code and site of service to estimate before locality adjustments.

Code selection at a glance

You saw / did	Report	Why it’s not 43235
Visualized UGI tract; brush/wash only	43235	Brush/wash is included in 43235.
Any biopsy (one or many)	43239	Diagnostic endoscopy is included in the surgical endoscopy.
Therapy (bleeding control, dilation, foreign body)	43255 / 43249 / 43247…	The therapeutic code is the comprehensive service for the session.
EUS performed	43237–43242	EUS codes replace the base diagnostic EGD code.