CPT 43239

Upper Endoscopy with Biopsy

Esophagogastroduodenoscopy (EGD), flexible, transoral, with biopsy, single or multiple.

20-30 minutes
3.25 work RVU
8 requirements

Documentation Requirements

  1. 1Indication for procedure
  2. 2Informed consent documented
  3. 3Sedation level and monitoring
  4. 4Extent of examination (esophagus, stomach, duodenum)
  5. 5Findings documented by anatomic location
  6. 6Biopsy site(s) and technique
  7. 7Specimen sent to pathology
  8. 8Complications 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.

Automate EGD with Biopsy Documentation

Scribeable captures all required elements for CPT 43239 from your patient conversation. Generate compliant notes in seconds.

Common Diagnoses

K21.0K25.9K29.70D13.1K22.70

Related Specialties

gastroenterologysurgery

Related Procedures

CPT 453783.69 work RVU

Colonoscopy

Diagnostic colonoscopy, flexible, with or without collection of specimen(s) by brushing or washing, through the stoma if applicable.

CPT 453804.43 work RVU

Colonoscopy w/ Biopsy

Colonoscopy, flexible, with biopsy, single or multiple, by forceps technique.

CPT 930000.29 work RVU

EKG

Electrocardiogram, routine ECG with at least 12 leads, with interpretation and report.

CPT 992042.60 work RVU

New Patient Level 4

New patient office visit with moderate level of medical decision making.

CPT 43239: Upper Endoscopy with Biopsy

Esophagogastroduodenoscopy (EGD), flexible, transoral, with biopsy, single or multiple.

Documentation Requirements

  1. Indication for procedure
  2. Informed consent documented
  3. Sedation level and monitoring
  4. Extent of examination (esophagus, stomach, duodenum)
  5. Findings documented by anatomic location
  6. Biopsy site(s) and technique
  7. Specimen sent to pathology
  8. 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.

Related Procedures

Specialties

Compare

Clinical Content

Resources

Getting Started