43239
Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope
Our Work > Good Faith Estimates > Biopsy of the Esophagus
Recent regulations require hospitals and health plans to publish prices of a subset of services. The hospital rule requires publication of “shoppable services,” those that can be scheduled in advance by a consumer. The Transparency in Coverage rule requires a list of 500 items and services to be published. Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope appears on both lists, and there is a standard service package available for it.This is a very common procedure performed millions of times per year in the United States.
An upper endoscopy is used to diagnose and sometimes treat conditions that affect the upper part of the digestive system. The upper digestive system includes the esophagus, stomach and beginning of the small intestine. The procedure is done with the help of a tiny camera on the end of a long, flexible tube. An endoscopy offers an opportunity to collect tissue samples (biopsy) to test for diseases and conditions that may be causing anemia, bleeding, inflammation or diarrhea. It can also detect some cancers of the upper digestive system. An endoscopy may be combined with a colonoscopy, or an examination of the large bowel. The upper GI Endoscopy will commonly be the first procedure undertaken but there is no set rule and the order may depend on the order the endoscopist considers is best for you.
Your service utilization may vary from this service package for a number of reasons, including your unique clinical profile and where you recieve your services. An endoscopy is sometimes combined with other procedures. We include optional fees for when an endoscopy is combined with a colonoscopy. However, note that other imaging or testing services may be performed which are not included in this service package.
This Service Package was generated using outpatient care setting. However, this service package may also be performed in the below care settings. Please confirm with your provider in which care setting you will receive services, as this may affect your cost.
- Inpatient: Discuss with your provider
- Outpatient facility: 54%
- Emergency room: 1%
- Free standing ASC: 45%
- Office: Discuss with your provider
Item Definitions
Index
Index
this is the fee for the service being defined; note that other codes may be used to define a similar service
Facility Fee
Facility Fee
these fees are most commonly associated with the index event; these may also be
paid to the facility in addition to the index fee
Professional Fee
Professional Fee
these fees are paid to clinicians for the work associated with this service
Optional Fee
Optional Fee
these services are often also billed with the index event, however may vary based on the patient’s individual circumstances
Ancillary Service
Ancillary Service
these are supply codes that identify other services that may be billed with the index event
Proposed Technical Definition
| association | base_code | code_type | estimated_charge | item_type | name |
|---|---|---|---|---|---|
| 1 | 43239 | CPT | 2368 | index | Biopsy of the esophagus, stomach, and/or upper small bowel |
| 1 | 43239 | CPT | 776 | professional_fee | Biopsy of the esophagus, stomach, and/or upper small bowel |
| 88305 | CPT | $340 | facility_fee | ||
| 0.813 | 88305 | CPT | 336 | professional_fee | Surgical Pathology Level 4 |
| 731 | CPT | $400 | |||
| 0.763795579 | 636 | Revenue Code | facility_fee | Drugs requiring detailed coding | |
| 0.700566233 | 750 | Revenue Code | facility_fee | Gastrointestinal services | |
| 0.532529655 | J2704 | HCPCS | 50.32 | facility_fee | Propofol injection |
| ? | J3010 | HCPCS | $15 | ||
| 0.440488062 | 310 | Revenue Code | facility_fee | Laboratory Pathology | |
| 0.422329442 | 45380 | CPT | 2585.565 | facility_fee | Flexible colonoscopy to destroy tumor(s), polyp(s), or other lesion(s) |
| 0.415569 | 312 | Revenue Code | facility_fee | Laboratory Histology | |
| 0.343415737 | 370 | Revenue Code | ancillary_service | Anesthesia | |
| 710 | Revenue Code | ancillary_service | Recovery Room | ||
| 0.320714288 | 250 | Revenue Code | ancillary_service | Pharmacy | |
| 10% | 45378 | CPT | $1,000 | optional_fee [facility] | |
| 10% | 45385 | CPT | $1,000 | optional_fee [facility] | |
| 10% | 45378 | CPT | $400 | optional_fee [professional] | |
| 10% | 45385 | CPT | $400 | optional_fee [professional] | |
| 30% | 813 | CPT | $460 | optional_fee [professional] | |
| 35% | 88342 | CPT | $100 | optional_fee [professional] | |
| 30% | 88312 | CPT | $100 | optional_fee [professional] | |
| 30% | 88313 | CPT | $100 | optional_fee [professional] |
Captured Spending (N=600,000)
| Decile | Base Fee (Facility + Professional) | Base Fee + Optional Fees |
| 1 | 4% | 3% |
| 2 | 1% | 1% |
| 3 | 4% | 3% |
| 4 | 10% | 6% |
| 5 | 5% | 4% |
| 6 | 8% | 6% |
| 7 | 11% | 9% |
| 8 | 4% | 6% |
| 9 | 4% | 6% |
| 10 | 46% | 58% |
Our Work > Good Faith Estimates > Biopsy of the Esophagus