CPT 43242 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 | • 22 - On Campus Outpatient Hospital • 21 - Inpatient Hospital |
| Common Modifiers | • None • 51 - Multiple procedures • 59 - Distinct Procedural Service |
| Complexity Level | Moderate |
| CMS | $250.69 Physician Fee Schedule |
National average reimbursement for CPT 43242 by major payers:
$377.44
$421.86
$444.54
$488.17
| 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 43242 | ||||||
United | 43242 | $1320.00 | 1073545299 - OREGON OUTPATIENT SURGERY CENTER LLC | 223883387 - (OR) OREGON OUTPATIENT SURGERY CENTER LLC | OR | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $1258.00 | 1942715826 - SAFETY HARBOR ASC COMPANY LLC, SAFETY HARBOR SURGERY CENTER | 320547161 | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $600.00 | 1184689408 - EVERGREEN EYE CENTER, PLLC, EYE ASSOCIATES NORTHWEST SURGERY CENTER | 911610832 - (WA) EYE ASSOCIATES NORTHWEST, PLLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $898.00 | 1144275900 - MT LAUREL ENDOSCOPY CENTER L P | 562350370 - (NJ) MT LAUREL ENDOSCOPY CENTER L P | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $1174.00 | 1225531544 - ANNE ARUNDEL-SCA SURGICENTER, LLC | 824763728 - (MD) ANNE ARUNDELSCA SURGICENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $721.00 | 1669585964 - WEST LAS VEGAS SURGERY CENTER,LLC, VALLEY VIEW SURGERY CENTER | 201898649 - (NV) WEST LAS VEGAS SURGERY CENTER LLC D/B/A VALLEY VIEW SURGERY CENTER | NV | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $518.00 | 1225387640 - PCET SURGERY CENTER LLC | 454288531 - (TN) PCET SURGERY CENTER LLC | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $1025.00 | 1710552278 - CHILDREN'S DENTAL SURGERY CENTER OF JACKSON LLC, CHILDREN'S DENTAL SURGERY OF JACKSON | 852790585 - (NJ) CHILDRENS DENTAL SURGERY CENTER OF JACKSON LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $1541.00 | 1871033878 - REDMOND AMBULATORY SURGERY CENTER, LLC | 813558711 - (WA) REDMOND AMBULATORY SURGERY CENTER LLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $1526.00 | 1720606932 - PHYSICIANS CLINIC INC | 470687317 - PHYSICIANS CLINIC INC | NE | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $2382.00 | 1891881926 - GASTRO-SURGI CENTER OF NEW JERSEY | 223472632 - (NJ) GASTRO-SURGI CENTER OF NJ | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $550.00 | 1386833044 - THE POTTSVILLE PA ENDOSCOPY ASC LP, SCHUYLKILL ENDOSCOPY CENTER | 260303896 | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $513.00 | 1518998764 - TENNESSEE PAIN SURGERY CENTER, LLC | 621790133 - (TN) TENNESSEE PAIN SURGERY CENTER LLC | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $575.00 | 1497367262 - SNKS ENTERPRISES LLC, SOL VALLEY SURGERY CENTER | 364932587 - (AZ) SNKS ENTERPRISES LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43242 | $1207.00 | 1124125331 - AMBULATORY SURGERY ASSOCIATES, LLC, BROOKSIDE SURGERY CENTER | 383237596 - (MI) AMBULATORY SURGERY ASSOCIATES | MI | 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 43242 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43242 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 43242 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 |
|---|---|---|
| 43238-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Transendoscopic Ultrasound-Guided Intramural Or Transmural Fine Needle Aspiration/Biopsy(S) Esophagus (Includes Endoscopic Ultrasound Examination Limited To The Esophagus Stomach Or Duodenum And Adjacent Structures) (Revised 01/01/2014) |
| 43240-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Transmural Drainage Of Pseudocyst (Includes Placement Of Transmural Drainage Catheter[S]/ Stent[S] When Performed And Endoscopic Ultrasound When Performed) (Revised 01/01/2014) |
| 43241-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Insertion Of Intraluminal Tube Or Catheter (Revised 01/01/2014) |
| 43242-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Transendoscopic Ultrasound-Guided Intramural Or Transmural Fine Needle Aspiration/Biopsy(S) (Includes Endoscopic Ultrasound Examination Of Theesophagus Stomach And Either The Duodenum Or A Surgically Altered Stomach Where The Jejunum Is Examined Distal To The Anastomosis) (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 43242. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43242 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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