CPT Code 43239 is one of the most frequently used codes in gastroenterology billing. Yet, it is also among the most denied when documentation or coding does not align with payer rules. This guide provides a detailed explanation of CPT 43239, including its description, use cases, ICD-10 pairings, applicable modifiers, reimbursement information, denial prevention strategies, and comparisons with related EGD codes.
By the end, you will have a clear understanding of how to bill CPT 43239 correctly and avoid claim delays or revenue loss.
What is CPT Code 43239?
CPT 43239 describes:
Esophagogastroduodenoscopy (EGD), flexible, transoral, with biopsy, single or multiple.
This procedure involves:
- Inserting a flexible endoscope through the mouth.
- Examining the esophagus, stomach, and duodenum.
- Taking one or more biopsy tissue samples for diagnostic purposes.
The biopsy may be performed to evaluate GERD, Barrett’s esophagus, gastritis, peptic ulcers, Crohn’s disease, anemia, or suspected malignancies.
When to Use CPT 43239
CPT 43239 is reported when a biopsy is performed during an upper GI endoscopy. It should not be confused with diagnostic EGD without biopsy or therapeutic procedures like lesion removal or bleeding control.
Clinical Scenarios Where CPT 43239 Applies
- GERD and Barrett’s esophagus – evaluating chronic reflux with possible tissue damage.
- Chronic gastritis or duodenitis – confirming inflammation through biopsy.
- Iron deficiency anemia – investigating possible gastrointestinal bleeding.
- Peptic ulcers – ruling out malignancy or infection.
- Celiac disease and Crohn’s disease – confirming diagnosis with small intestine tissue samples.
- Suspected gastric or esophageal cancer – collecting biopsy for pathology.
ICD-10 Codes That Support Medical Necessity for CPT 43239
Correct ICD-10 coding is critical to avoid denials. Claims may be rejected if the diagnosis does not justify medical necessity.
Common ICD-10 Codes for CPT 43239
| ICD-10 Code | Description |
| K21.0 | GERD with esophagitis |
| K29.70 | Gastritis, unspecified, without bleeding |
| K22.70 | Barrett’s esophagus without dysplasia |
| D50.0 | Iron deficiency anemia secondary to chronic blood loss |
| C16.9 | Malignant neoplasm of stomach, unspecified |
| C15.9 | Malignant neoplasm of esophagus, unspecified |
| K25.4 | Chronic gastric ulcer with hemorrhage |
| K22.2 | Esophageal obstruction |
Always check your MAC’s LCD (Local Coverage Determination) for approved ICD-10 codes before billing.
Modifiers for CPT Code 43239
Proper use of modifiers ensures accurate claim submission and reduces denials.
Common Modifiers Used with CPT 43239
| Modifier | Description | When to Use |
| 59 | Distinct Procedural Service | When performed with another EGD code at a different site or for a different reason |
| 53 | Discontinued Procedure | If procedure started but stopped due to clinical risk |
| 22 | Increased Procedural Service | When significantly more work is required |
| 51 | Multiple Procedures | If multiple procedures were performed in one session |
CPT 43239 vs. Related EGD Codes
Understanding differences between CPT 43239 and other endoscopy codes avoids miscoding.
| CPT Code | Description | Key Use |
| 43235 | Diagnostic EGD without biopsy | Visual inspection only |
| 43239 | EGD with biopsy | Biopsy for diagnostic purposes |
| 43250 | EGD with lesion removal (hot biopsy) | Removal of tissue using heat |
| 43251 | EGD with polyp/lesion removal by snare | Therapeutic removal |
| 43255 | EGD with control of bleeding | Active bleeding treated |
Reimbursement for CPT 43239
CPT 43239 is reimbursed under the Medicare Physician Fee Schedule (MPFS) and by commercial payers. Rates vary depending on location and payer policies.
- Reimbursement is higher than 43235 because biopsy increases complexity.
- Payment can be denied if:
- Documentation does not confirm biopsy.
- ICD-10 code does not support medical necessity.
- Incorrect or missing modifiers are applied.
How to Avoid Denials for CPT 43239
Denials for CPT 43239 usually occur due to documentation gaps or unsupported coding.
Common Denial Reasons
- Missing ICD-10 code supporting biopsy.
- Vague procedure notes without biopsy site or reason.
- Overlapping use of multiple EGD codes without distinction.
- Improper use of modifiers.
Best Practices for Clean Claims
- Always pair CPT 43239 with a covered ICD-10 code.
- Clearly document site, purpose, and clinical justification for biopsy.
- Use modifiers only when justified and supported in notes.
- Verify payer-specific coverage and pre-authorization if required.
Conclusion
CPT Code 43239 represents an EGD with biopsy, one of the most common yet often denied procedures in gastroenterology billing. Correct reimbursement depends on accurate ICD-10 coding, modifier use, and precise documentation.
By distinguishing CPT 43239 from related endoscopy codes and following payer LCD guidelines, practices can minimize denials, ensure compliance, and maximize revenue.
If your claims for CPT 43239 are being denied or underpaid, professional gastroenterology billing services can help streamline compliance and recover lost revenue.
Frequently Asked Questions About CPT 43239
Can CPT 43239 be billed with another EGD code?
Yes, but only if procedures are distinct and performed for different reasons. Modifier 59 may be needed.
How many times can CPT 43239 be billed in one session?
Only once per session. The code covers single or multiple biopsies.
Do I need a modifier if CPT 43239 is the only procedure?
No modifier is needed unless payer guidelines specify otherwise.
What is the reimbursement difference between CPT 43235 and 43239?
CPT 43239 typically reimburses more than 43235 because of the biopsy.
What documentation is required for CPT 43239?
The operative note must detail biopsy location, medical necessity, and pathology submission.
