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See a sample rate comparisonCPT 43196 Fee Schedule
Last Verified: October 2026
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
Esophagus Enlargement, Exam Of The Esophagus Aided By A Scope (Endoscope). The Procedure Inserts A Device To Enlarge Or Open Up The Esophagus.
| Key Fact | Detail |
|---|---|
| Service Type | Surgery Surgical Procedures on the Digestive System |
| Common Place of Service | 22 - On Campus Outpatient Hospital 24 - Ambulatory Surgical Center |
| Common Modifiers | GC - Service performed by resident under supervision 58 - Staged or related procedure during postoperative period |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $171.68 national non-facility rate (2026) · View Medicare rates for 43196 |
| Medicaid Fee Schedule | $136.75 median of the 8 states in the free preview · View Medicaid rates for 43196 |
National average reimbursement for CPT 43196 by major payers:
$271.06
$271.29
$275.38
$336.76
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CPT 43196
5 of 25 sample ratesHigher to lower in this preview
Rachel Niec
$481.20Published rateLayth Al-Jashaami
$372.58Published rateAnna Krigel
Columbia University In The City Of New York
$306.61Published rateChristopher Raio
St Joseph Hospital
$290.29Published rateStephen Koster
Deaconess Hospital Inc
$159.88Published rate
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See a sample payer proposalCPT 43196 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43196 code is part of the Surgery services used for Surgical Procedures on the Digestive System. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 43196 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 43192-CPT | Moderate | Esophagoscopy Rigid Transoral; W/ Direct Submucosal Inject(S), Esophagoscopy Rigid Transoral; With Directed Submucosal Injection(S) |
| 43193-CPT | Moderate | Esophagus Exam With Scope, Exam Of The Esophagus Using A Scope (Endoscope). The Procedure May Include Taking A Sample Of Tissue For Testing (Biopsy). |
| 43194-CPT | Moderate | Esophagus Exam With Scope, An Exam Of The Esophagus Using A Scope (Endoscope) With Removal Of A Foreign Object From The Esophagus. |
| 43196-CPT | Moderate | Esophagus Enlargement, Exam Of The Esophagus Aided By A Scope (Endoscope). The Procedure Inserts A Device To Enlarge Or Open Up The Esophagus. |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43196. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43196 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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