CPT 43239: Upper Endoscopy with Biopsy
Documentation Requirements
- Indication for procedure
- Informed consent documented
- Sedation level and monitoring
- Extent of examination (esophagus, stomach, duodenum)
- Findings documented by anatomic location
- Biopsy site(s) and technique
- Specimen sent to pathology
- Complications or lack thereof
Billing Tips
- Do not bill 43235 (diagnostic EGD) separately with 43239
- Multiple biopsies in same session = single 43239
- Document all anatomic locations examined and biopsied
- Separate pathology specimens should be labeled by site
- H. pylori testing may be separately billable
Frequently Asked Questions
What documentation is needed for 43239?
Document indication, consent, sedation, extent of exam (esophagus through duodenum), all findings by location, biopsy sites, technique, and pathology orders. Scribeable structures these elements automatically.
Can Scribeable generate EGD procedure notes?
Yes, Scribeable captures your endoscopy dictation and produces comprehensive procedure notes with findings by anatomic location, biopsy details, and all required documentation elements.