CPT 43259 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 • 24 - Ambulatory Surgical Center |
| Common Modifiers | • None • 51 - Multiple procedures • 59 - Distinct Procedural Service |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 43259 |
National average reimbursement for CPT 43259 by major payers:
$329.81
$338.71
$360.61
$402.26
| 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 43259 | ||||||
United | 43259 | $242.74 | 1790057420 - BAMA HEART DOC, P.C., ALABAMA HEART AND VASCULAR MEDICINE | 451471722 - (AL) BAMA HEART DOC, PC DBA ALABAMA HEART & VASCULAR MEDICINE | AL | Interventional Cardiology Physician (207RI0011X) |
United | 43259 | $833.00 | 1124058946 - LUTHERVILLE SURGICENTER, LLC | 522109473 - (MD) LUTHERVILLE SURGICENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1528.00 | 1104298009 - RED CEDAR SURGERY CENTER, LLC, RED CEDAR SURGERY CENTER, PLLC | 472947364 - (MI) RED CEDAR SURGERY CENTER, PLLC | MI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $480.00 | 1376657890 - SURGICAL SPECIALTY SUITES, INC | 61784797 - (MD) SURGICAL SPECIALTY SUITES INC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $688.00 | 1922052364 - AMARILLO SURGERY AND ENDOSCOPY, LP, ADC ENDOSCOPY SPECIALISTS | 203590535 - (TX) AMARILLO SURGERY AND ENDOSCOPY LP | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1275.00 | 1386381408 - CYPRESS AMBULATORY SURGERY CENTER, LLC, WELLNESS AVENUE SURGERY CENTER | 823481913 | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1364.00 | 1043283906 - NAUGATUCK VALLEY ENDOSCOPY CENTER, LLC, WATERBURY SURGERY CENTER | 260078381 - (CT) NAUGATUCK VALLEY ENDOSCOPY CENTE | CT | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $242.74 | 1790057420 - BAMA HEART DOC, P.C., ALABAMA HEART AND VASCULAR MEDICINE | 451471722 - (AL) BAMA HEART DOC, PC DBA ALABAMA HEART & VASCULAR MEDICINE | AL | Interventional Cardiology Physician (207RI0011X) |
United | 43259 | $928.00 | 1962938332 - BANNER UNION HILLS SURGERY CENTER LLC | 901164193 - (AZ) BANNER UNION HILLS SURGERY CENTER LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1258.00 | 1043803877 - PALM BEACH INTERNATIONAL SURGERY CENTER LLC, PALM BEACH INTERNATIONAL SURGERY CENTER AT THE PALEY INSTITUTE | 384092545 - (FL) PALM BEACH INTERNATIONAL SURGERY CENTER LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $840.00 | 1073571766 - BOCA RATON OUTPATIENT SURGERY & LASER CENTER LTD | 650241934 - (FL) BOCA RATON OUTPATIENT SURGERY LASER CENTER LTD | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1276.00 | 1881969269 - SURGERY CENTRE OF SW FLORIDA LLC, CAPE HEALTH SURGERY CENTER | 454068750 | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1747.00 | 1083902423 - CHASKA PLAZA SURGERY CENTER, LLC, TWO TWELVE SURGERY CENTER | 450975783 - (MN) CHASKA PLAZA SURGERY CENTER LLC | MN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $764.00 | 1508318411 - INTERVENTIONAL SPINE CENTER, LLC | 263161503 - (CA) INTERVENTIONAL SPINE CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $550.00 | 1053385856 - JACKSON OPHTHALMOLOGY ASC LLC, PHYSICIANS SURGERY CENTER | 752842260 - (TN) JACKSON OPHTHALMOLOGY ASC, LLC DBA PHYSICIANS SUR | TN | 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 43259 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43259 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 43259 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) |
| 43249-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Transendoscopic Balloon Dilation Of Esophagus(Less Than 30 Mm Diameter) (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) |
| 43259-CPT | Moderate | Esophagogastroduodenoscopy Flexible Transoral; With Endoscopic Ultrasound Examination Including The Esophagus Stomach And Either The Duodenum Ora 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 43259. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43259 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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