Aetna Gastroenterology
Compare Aetna's contracted rates for gastroenterology services against national averages and other major payers. Use these benchmarks to identify underpaid codes, prepare for contract renegotiations, and validate your reimbursement strategy.
Aetna's commercial fee schedules are typically tiered by site-of-service and product line, with distinct rate structures for HMO, PPO, and Medicare Advantage networks.
Introduction
Gastroenterology reimbursement is heavily procedural, with colonoscopy and upper endoscopy accounting for the majority of GI revenue. Site-of-service is a major factor — ambulatory surgery centers (ASCs) and hospital outpatient departments receive significantly different facility fees for identical procedures, and the shift toward ASC-based GI has accelerated in recent years.
GI procedures are billed using CPT codes that distinguish between diagnostic and therapeutic interventions (e.g., colonoscopy with vs. without polypectomy). Payer contracts for high-volume procedures like screening colonoscopy are among the most negotiated rates in outpatient surgery, making benchmarking against national averages critical for GI practices and ASC operators.
Upper Endoscopy (EGD)
Esophagogastroduodenoscopy
Upper GI endoscopy for evaluation and treatment of esophageal, gastric, and duodenal pathology. EGD with biopsy is the most commonly performed upper GI procedure, with reimbursement varying by whether the procedure is diagnostic or includes therapeutic intervention.
| Billing Code | Description | Revenue Code | Description | Avg. National Aetna Rate |
|---|---|---|---|---|
| 43235 | Esophagogastroduodenoscopy Flexible Transoral; Diagnostic Including Collection Of Specimen(S) Bybrushing Or Washing When Performed (Separate Procedure) (Revised 01/01/2014) | 0750 | Gastroenterology | $430.11 |
| 43239 | Upper Gastrointestinal Endosco, Upper Gastrointestinal Endoscopy Including Esophagusstomach And Either The Duodenum Andor Jejunumas Appropriate With Biopsy Single Or Multiple | 0750 | Gastroenterology | $538.52 |
| 43249 | Upper Gastrointestinal Endosco, Upper Gastrointestinal Endoscopy Including Esophagusstomach And Either The Duodenum Andor Jejunumas Appropriate With Balloon Dilation Of Esophag Us (Less Than | 0750 | Gastroenterology | $1,224.16 |
| 43244 | Exam Of Digestive Tract, Exam Using A Scope (Endoscope) To View The Esophagus Stomach And Part Of The Intestines. Enlarged Veins (Varices) In The Esophagus And Stomach Are Treated At This Time. | 0750 | Gastroenterology | $377.23 |
Colonoscopy
Colonoscopy Procedures
Lower GI endoscopy for colorectal cancer screening, surveillance, and therapeutic intervention. Screening colonoscopy is a high-volume, ACA-mandated preventive service with no patient cost-sharing, but facility and professional reimbursement rates vary significantly across payers.
| Billing Code | Description | Revenue Code | Description | Avg. National Aetna Rate |
|---|---|---|---|---|
| 45378 | Colonoscopy Flexible Proxima, Colonoscopy Flexible Proximal To Splenic Flexurediagnostic With Or Without Collection Of Specimen(S) By Brushing Or Washing With Or Without Colon Decompression | 0750 | Gastroenterology | $522.30 |
| 45380 | Intestinal Exam (Colonoscopy), An Exam Of The Lower Part Of The Intestine (Colon) Using A Scope (Colonoscopy). The Procedure May Include Collection Of Cells Or Tissue For Testing (Biopsy). | 0750 | Gastroenterology | $651.25 |
| 45385 | Colonoscopy To Remove Growth, An Exam Of The Intestine Using A Scope (Colonoscopy). The Procedure Includes Removing One Or More Tissue Growths Such As A Tumor Or Polyp. | 0750 | Gastroenterology | $696.85 |
| 45384 | Colonoscopy Flexible Proxima, Colonoscopy Flexible Proximal To Splenic Flexure Withremoval Of Tumor(S) Polyp(S) Or Other Lesion(S) By Hot Biopsy Forceps Or Bipolar Cautery | 0750 | Gastroenterology | $687.87 |
Other GI Procedures
Advanced Endoscopy & Diagnostics
Specialized GI procedures including ERCP, capsule endoscopy, flexible sigmoidoscopy, and motility studies. These procedures carry higher reimbursement but lower volume, and are typically performed in hospital outpatient or specialized endoscopy center settings.
| Billing Code | Description | Revenue Code | Description | Avg. National Aetna Rate |
|---|---|---|---|---|
| 45330 | Scope Exam Of Large Intestine, An Exam Of The Large Intestine Using A Scope (Sigmoidoscopy). The Procedure May Include Taking A Sample Of Tissue For Testing (Biopsy). | 0750 | Gastroenterology | $245.49 |
| 43260 | Endoscopic Retrograde Cholangiopancreatography (Ercp); Diagnostic Including Collection Of Specimen(S) By Brushing Or Washing When Performed(Separate Procedure) (Revised 01/01/2014) | 0750 | Gastroenterology | $475.63 |
| 43274 | Ercp Duct Stent Placement, Endoscopic Retrograde Cholangiopancreatography Ercp With Placement Of Endoscopic Stent Into Biliary Or Pancreatic Duct Including Pre And Post Dilation And Guide Wire Passage When Performed Including Sphincterotomy When Performed Each Stent | 0750 | Gastroenterology | $670.09 |
| 43246 | Upper Gastrointestinal Endosco, Upper Gastrointestinal Endoscopy Including Esophagusstomach And Either The Duodenum Andor Jejunumas Appropriate With Directed Placement Of Percu Taneous | 0750 | Gastroenterology | $319.17 |
GI Office Visits
Evaluation & Management
Office and outpatient E&M visits for gastroenterology consultations, pre-procedural evaluations, and chronic disease management. GI E&M visits are a smaller share of revenue but essential for procedure scheduling and patient retention.
| Billing Code | Description | Revenue Code | Description | Avg. National Aetna Rate |
|---|---|---|---|---|
| 99204 | Office O P New Mod 45 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of A New Patient Which Requires A Medically Appropriate History And Or Examination And Moderate Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 45 Minutes Must Be Met Or Exceeded | 0510 | Clinic | $175.56 |
| 99205 | Office O P New Hi 60 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of A New Patient Which Requires A Medically Appropriate History And Or Examination And High Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 60 Minutes Must Be Met Or Exceeded | 0510 | Clinic | $227.41 |
| 99214 | Office O P Est Mod 30 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of An Established Patient Which Requires A Medically Appropriate History And Or Examination And Moderate Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 30 Minutes Must Be Met Or Exceeded | 0510 | Clinic | $119.38 |
| 99215 | Office O P Est Hi 40 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of An Established Patient Which Requires A Medically Appropriate History And Or Examination And High Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 40 Minutes Must Be Met Or Exceeded | 0510 | Clinic | $165.55 |
What is a fee schedule?
A fee schedule is a list of negotiated prices that healthcare providers charge for specific services. These prices vary by payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the applicable fee schedule helps providers optimize billing for accurate reimbursement and helps patients anticipate out-of-pocket costs.
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.
View gastroenterology fee schedules for other major payers
What is Price Transparency?
The federal Price Transparency Rule took effect in July 2022, requiring all commercial payers to publicly disclose their prices through machine-readable files (MRFs). This landmark regulation mandates that insurance companies make healthcare costs transparent to the public. Read more here.
PayerPrice gives you access to the actual prices that insurers are legally required to publish under the Price Transparency Rule. We deliver this data exactly as reported in the insurers' machine-readable files, giving you an accurate view of negotiated rates. While insurers occasionally report incomplete or inaccurate data, our platform ensures you see the same information that insurers have made publicly available.
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