CPT 43255 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 | • 21 - Inpatient Hospital • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • 59 - Distinct Procedural Service • XS - Separate Structure |
| Complexity Level | Moderate |
| CMS | $587.09 Physician Fee Schedule |
National average reimbursement for CPT 43255 by major payers:
$608.78
$700.71
$777.38
$951.46
| 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 43255 | ||||||
United | 43255 | $210.94 | 1366493652 - NEHME GABRIEL | 204622819 - GASTROENTEROLOGY AND NUTRITION | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $283.14 | 1457347981 - CELIA QUINNONEZ | 593210246 - PROFESSIONAL GASTROENTEROLOGY | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $704.45 | 1922210582 - JUSTIN NUDELL | 270709861 - FLORIDA DIGESTIVE HEALTH SPECIALISTS, LLP | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $820.71 | 1184770083 - CHARLES LOEWE | 270709861 - FLORIDA DIGESTIVE HEALTH SPECIALISTS, LLP | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $538.91 | 1750624086 - RAHMAN NAKSHABENDI | 20732411 - IMAD AL-NAKSHABENDI MD PA | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $2554.16 | 1760640130 - LUIS SERVIN ABAD | 410695596 - ST CLOUD HOSPITAL | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $1343.01 | 1558350975 - RONALD LEVY | 203400983 - GASTRO HEALTH, LLC | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $2470.53 | 1831191337 - BRADFORD JOSEPH | 591784470 - BORLAND-GROOVER CLINIC, P.A. | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $571.35 | 1619070851 - LAKHINDER BHATIA | 522370002 - (FL) DIGESTIVE DISEASE CENTER P A (<10 NPIs) | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $640.48 | 1841283546 - JOHN KAUFMAN | 112652156 - (NY) JOHN C KAUFMAN MD PC (<10 NPIs) | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $1107.31 | 1730198052 - TAWFIK CHAMI | 923479126 | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $1293.36 | 1063555894 - MUHAMMAD HASAN | 593214635 - FLORIDA HOSPITAL MEDICAL GROUP INC | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $1140.44 | 1407169113 - SOHAIB HASSAN | 593214635 - FLORIDA HOSPITAL MEDICAL GROUP INC | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $820.71 | 1235335076 - VANESSA KUWAJIMA | 270709861 - FLORIDA DIGESTIVE HEALTH SPECIALISTS, LLP | FL | Gastroenterology Physician (207RG0100X) |
United | 43255 | $238.42 | 1033149752 - AMMAR HEMAIDAN | 593684659 - (FL) ADVANCED GASTROENTEROLOGY HEALTH CARE CENTERS (10-100 NPIs) | FL | Gastroenterology Physician (207RG0100X) |
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 43255 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43255 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 43255 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 |
|---|---|---|
| 43248-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Insertion Of Guide Wire Followed By Passage Of Dilator(S) Through Esophagus Over Guide Wire (Revised 01/01/2014) |
| 43250-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Removal Of Tumor(S) Polyp(S) Or Other Lesion(S) By Hot Biopsy Forceps (Revised 01/01/2015) |
| 43251-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Removal Of Tumor(S) Polyp(S) Or Other Lesion(S) By Snare Technique (Revised 01/01/2014) |
| 43255-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Control Of Bleeding Any Method (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 43255. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43255 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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