CPT 43197 Fee Schedule
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.
| Key Fact | Detail |
|---|---|
| Service Type | • Surgery • Surgical Procedures on the Digestive System |
| Common Place of Service | • 11 - Office • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • 59 - Distinct Procedural Service • XU - Unusual Non-Overlapping Service |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 43197 |
National average reimbursement for CPT 43197 by major payers:
$230.15
$256.26
$269.52
$333.14
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
Select a payer to view fee schedule data Choose a payer from the options above to see rates for CPT 43197 | ||||||
United | 43197 | $785.00 | 1235683798 - ASSOCIATED SURGICAL CENTER LLC | 813492018 - (IL) ASSOCIATED SURGICAL CENTER LLC | IL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $326.39 | 1710036892 - MARCUS OBEIUS | 350593390 - DEACONESS HOSPITAL INC | IN | Emergency Medicine Physician (207P00000X) |
United | 43197 | $1000.00 | 1326469172 - EHI SURGERY CENTER AUSTIN, LLC | 464266877 - (TX) EHI SURGERY CENTER AUSTIN LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $3557.00 | 1497352934 - LEXINGTON HEALTH INC, LMC LEXINGTON ASC | 852276567 - LEXINGTON HEALTH INC | SC | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $326.39 | 1386962223 - KELLI MATHEW | 350593390 - DEACONESS HOSPITAL INC | KY | Pulmonary Disease Physician (207RP1001X) |
United | 43197 | $417.00 | 1467582437 - NORTH FLORIDA SURGERY CENTER INC, NORTH FLORIDA SURGERY CENTER | 593377918 - (FL) NORTH FLORIDA SURGERY CENTER INC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $600.00 | 1780752352 - PREMIER SURGERY CENTER OF SANTA MARIA LLC | 203502741 - (CA) PREMIER SURGERY CENTER OF SANTA MARIA, INC. | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $774.00 | 1346868890 - UPNT SURGERY LLC | 371939831 - (TX) UPNT SURGERY LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $2701.00 | 1417912098 - BAILEY SQUARE AMBULATORY SURGICAL CENTER, LTD | 752467365 - (TX) BAILEY SQUARE AMBULATORY SURGICAL CENTER LTD | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $600.00 | 1427577840 - DIALYSIS ACCESS CENTER OF CINCINNATI, INC. | 815023998 - (OH) DIALYSIS ACCESS CENTER OF CINCINNATI INC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $686.00 | 1184699241 - SAN LUIS OBISPO CA ENDOSCOPY ASC LP, TEMPLETON ENDOSCOPY CENTER | 201965605 - (CA) SAN LUIS OBISPO CA ENDOSCOPY ASC LP | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $750.00 | 1871204511 - LAWRENCEVILLE CENTER FOR PAIN AND SPINE, LLC | 920689448 - (GA) LAWRENCEVILLE CENTER FOR PAIN AND SPINE LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $523.00 | 1013522127 - SARC BY HSH ASC PINE BLUFF, LLC, SARC BY HSH ASC PINE BLUFF LLC | 850884465 - (AR) SARC BY HSH ASC PINE BLUFF LLC | AR | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $670.00 | 1396142733 - DIALYSIS ACCESS SERVICES, LLC | 472322456 - (MD) DIALYSIS ACCESS SERVICES LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43197 | $2782.00 | 1417912098 - BAILEY SQUARE AMBULATORY SURGICAL CENTER, LTD | 752467365 - (TX) BAILEY SQUARE AMBULATORY SURGICAL CENTER LTD | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 43197 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43197 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 43197 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 |
|---|---|---|
| 43197-CPT | Moderate | Esophagoscopy, Flexible, Transnasal; Diagnostic, Including Collection Of Specimen(S) By Brushing Or Washing, When Performed (Separate Procedure) |
| 43198-CPT | Moderate | Once Per Dos Esophagoscopy, Flexible, Transnasal; W/Biopsy, Single Or Multiple |
| 43200-CPT | Moderate | Esophagoscopy Flexible Transoral; Diagnostic Including Collection Of Specimen(S) By Brushing Orwashing When Performed (Separate Procedure) (Revised 01/01/2014) |
| 43202-CPT | Moderate | Esophagoscopy Flexible Transoral; With Biopsy Single Or Multiple (Revised 01/01/2014) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43197. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43197 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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