43235 — Diagnostic exam of esophagus, stomach, and/or upper small bowel using a flexible endoscope

What the market charges

Across 21,984 negotiated rates, the middle 80% fall between $145 and $698, with a median of $327.

What Medicare pays

Medicare allowed an average of $145 for this code, across 206,051 services billed by 7,186 providers. At the median, the market charges 2.3 times what Medicare pays for this code.

Where this is billed, and what it costs there

The states billing 43235 most, by Medicare service volume, each compared against the national average of $145. Each links to the providers Mishe lists there.

• California — 571 providers billed it, Medicare allowed $170 — 17% above the national average
• Texas — 476 providers billed it, Medicare allowed $144 — 1% below the national average
• Florida — 466 providers billed it, Medicare allowed $153 — 6% above the national average
• Pennsylvania — 405 providers billed it, Medicare allowed $154 — 6% above the national average
• Ohio — 383 providers billed it, Medicare allowed $145 — level with the national average
• Tennessee — 197 providers billed it, Medicare allowed $139 — 4% below the national average
• North Carolina — 272 providers billed it, Medicare allowed $156 — 8% above the national average
• Massachusetts — 235 providers billed it, Medicare allowed $130 — 10% below the national average

Claim-editing rules

These are National Correct Coding Initiative procedure-to-procedure edits — the rules a payer applies when deciding whether two codes billed together are both payable.

Codes this one absorbs

Billed together, 43235 is the payable code and these are not separately payable. 239 pairs in total.

• 12001 — a modifier may allow both to be paid
• 12002 — a modifier may allow both to be paid
• 12004 — a modifier may allow both to be paid
• 12005 — a modifier may allow both to be paid
• 12006 — a modifier may allow both to be paid
• 12007 — a modifier may allow both to be paid
• 12011 — a modifier may allow both to be paid
• 12013 — a modifier may allow both to be paid
• 12014 — a modifier may allow both to be paid
• 12015 — a modifier may allow both to be paid
• 12016 — a modifier may allow both to be paid
• 12017 — a modifier may allow both to be paid

Codes that absorb this one

Billed alongside any of these, 43235 is not separately payable. 90 pairs in total.

• 41150 — a modifier may allow both to be paid
• 43192 — no modifier can override this edit
• 43193 — no modifier can override this edit
• 43194 — no modifier can override this edit
• 43195 — no modifier can override this edit
• 43196 — no modifier can override this edit
• 43210 — no modifier can override this edit
• 43233 — no modifier can override this edit
• 43236 — no modifier can override this edit
• 43237 — no modifier can override this edit
• 43238 — no modifier can override this edit
• 43239 — no modifier can override this edit

Care pathways that use this code

Mishe builds care pathways that route a member to the right setting before anything is billed. These include 43235.

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Other codes

• 99214 — Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more
• 99213 — Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more
• 97530 — Therapy procedure using functional activities
• 99232 — Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes
• 97112 — Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes
• 99233 — Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes
• 88305 — Pathology examination of tissue using a microscope, intermediate complexity
• 99309 — Subsequent nursing facility care with moderate level of medical decision making, per day, if using time, at least 30 minutes
• 87798 — Detection test by nucleic acid for organism, amplified probe technique
• 98941 — Chiropractic manipulative treatment, 3-4 spinal regions

Deploy this for your team

Every figure on this page came from published payer and Medicare data, assembled by Mishe. The same pricing, claim-editing and care-pathway intelligence runs underneath the plans Mishe operates.

• Contact Mishe to learn how to deploy these resources for your team
• Guides to direct-pay healthcare
• Cash prices by procedure
• Find a provider by state

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