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 |
| CMS | $216.40 Physician Fee Schedule |
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 | $1535.00 | 1083659866 - ORTHOPAEDIC SURGERY CENTER OF SAN ANTONIO LP, FOUNDATION SURGERY AFFILIATE OF SAN ANTONIO LP | 742976746 - (TX) ORTHOPAEDIC SURGERY CENTER OF SAN ANTONIO LP | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $997.00 | 1609871847 - THE SURGERY CENTER, LLC | 582520623 - (GA) THE SURGERY CENTER LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $675.00 | 1881125870 - RENAL ASSOCIATES, P.A. | 742083988 - (TX) RENAL ASSOCIATES, PA | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1790.00 | 1215000997 - CHILDREN'S NATIONAL AMBULATORY SURGERY CENTER | 530196580 - CHILDRENS HOSPITAL | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $409.44 | 1801987854 - MICHAEL PETERS | 350593390 - DEACONESS HOSPITAL INC | IN | Emergency Medicine Physician (207P00000X) |
United | 43259 | $575.00 | 1588203723 - SOUTHWEST CARDIOVASCULAR INTERVENTIONAL CENTER, LLC | 832560085 - (AZ) SOUTHWEST CARDIOVASCULAR INTERVENTIONAL CENTER LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1875.00 | 1447995311 - NEW ENGLAND BAPTIST SURGERY CENTER LLC | 874311329 - (MA) NEW ENGLAND BAPTIST SURGERY CENTER LLC | MA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $475.00 | 1164871075 - CENTRAL ARIZONA GI & LIVER INSTITUTE LLC | 812583508 | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1666.00 | 1477584621 - HANOVER NJ ENDOSCOPY ASC LLC, HANOVER ENDOSCOPY CENTER | 201272329 - (NJ) HANOVER NJ ENDOSCOPY ASC LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1600.00 | 1912909169 - KIPS BAY ENDOSCOPY CENTER, LLC | 134243635 - (NY) KIPS BAY ENDOSCOPY CENTER LLC | NY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $715.00 | 1750528717 - ROUND ROCK SURGERY CENTER LLC, ADVANCED SURGICAL CENTER - ROUND ROCK | 260856139 - (TX) ROUND ROCK SURGERY CENTER LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $2709.00 | 1902063605 - PENN PRESBYTERIAN MEDICAL CENTER SPU | 232810852 - PRESBYTERIAN MEDICAL CENTER OF THE UNIVERSITY OF PENNSYLVANIA HEALTH | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1036.00 | 1982238465 - PROFESSIONAL RECREATION ORGANIZATION, INC. | 931484998 - (WA) PRO SURGERY CENTER LLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $1233.00 | 1437419660 - ADVANCED SURGERY CENTER OF METAIRIE LLC | 453386956 - (LA) ADVANCED SURGERY CENTER OF METAIRIE | LA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43259 | $560.00 | 1043216617 - TRIAD SURGERY CENTER LLC, TRIAD EYE MEDICAL CLINIC AND CATARACT INSTITUTE PLLC | 465002052 - (OK) TRIAD EYE INSTITUTE, PLLC | OK | 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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