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See a sample rate comparisonCPT 43242 Fee Schedule
Last Verified: September 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.
Endoscopic Procedure, Upper Gastrointestinal Endoscopy Including Esophagus Stomach And Either The Duodenum And/Or Jejunum As Appropriate; With Transendoscopic Ultrasound-Guided Intramural Or Transmural Fine Needle Aspiration/Biopsy(S)(Includes Endoscopic Ultrasound Examination Of The Esophagus Stomach And Either The Duodenum And/Or Jejunum As Appropriate)
| 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 |
| Medicare Fee Schedule | View Medicare rates for 43242 |
| Medicaid Fee Schedule | View Medicaid rates for 43242 |
National average reimbursement for CPT 43242 by major payers:
$377.44
$421.86
$444.54
$477.80
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CPT 43242
5 of 25 sample ratesHigher to lower in this preview
Tuscan Surgery Center At Las Colinas, LLC, Tuscan Surgery Center At Las Colinas
$2,172.00Published rateMonocacy Surgery Center LLC
Monocacy Surgery Center
$1,258.00Published rateBsc 1 LLC
$947.00Published rateSmart Pain Surgery Center At Germantown, LLC, Clearway Surgery Center Of Germantown
Smart Pain Surgery Center At Germantown LLC
$611.00Published rateAndrea Infantino
Deaconess Hospital Inc
$218.47Published rate
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See a sample payer proposalCPT 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 | Upper Gastrointestinal Endosco, Upper Gastrointestinal Endoscopy Including Esophagusstomach And Either The Duodenum Andor Jejunumas Appropriate With Transendoscopic Tube Or Cat Heter Placement |
| 43242-CPT | Moderate | Endoscopic Procedure, Upper Gastrointestinal Endoscopy Including Esophagus Stomach And Either The Duodenum And/Or Jejunum As Appropriate; With Transendoscopic Ultrasound-Guided Intramural Or Transmural Fine Needle Aspiration/Biopsy(S)(Includes Endoscopic Ultrasound Examination Of The Esophagus Stomach And Either The Duodenum And/Or Jejunum As Appropriate) |
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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