43243

⚕️CPT 43243 — EGD with Injection Sclerotherapy of Esophageal/Gastric Varices

---

📋 Quick Reference

Field	Detail
CPT Code	43243
Full Descriptor	Esophagogastroduodenoscopy, flexible, transoral; with injection sclerotherapy of esophageal/gastric varices
Short Descriptor	EGD w/ injection sclerotherapy, varices
Category	Upper GI Endoscopy — Therapeutic
Specialty	Gastroenterology · General Surgery · Hepatology
Global Period	000 — Zero Days
wRVU (Work)	~3.50 CMS PFS 2026
Assistant Payable	❌ No
Bilateral Concept	❌ No
Moderate Sedation	✅ Bundled — do not separately report 99152-99153
Multiple Procedure Reduction	✅ Yes — 50% reduction applies when additional procedures performed same session
Facility / Non-Facility	Both applicable — RVU totals differ per CMS PFS

---

🔬 Procedure Description

CPT 43243 describes a flexible, transoral esophagogastroduodenoscopy (EGD) performed with injection sclerotherapy directed at esophageal and/or gastric varices.

Procedural Sequence

1. Scope Introduction — A flexible fiber-optic or video endoscope is passed transorally through the oropharynx and advanced through the esophagus, stomach, and into the duodenum and/or proximal jejunum as clinically appropriate.
2. Variceal Identification & Classification — Esophageal or gastric varices are identified and assessed. Esophageal varices are commonly graded using the Paquet or Baveno classification systems; gastric varices are typed per the Sarin classification (GOV1, GOV2, IGV1, IGV2).
3. Sclerosant Selection — Common sclerosing agents include:
   • Sodium morrhuate — most widely used in the U.S.
   • Ethanolamine oleate — frequently used for esophageal varices
   • Sodium tetradecyl sulfate — used in both esophageal and gastric varices
   • Polidocanol — common in European practice
   • Cyanoacrylate glue (N-butyl-2-cyanoacrylate) — preferred for gastric varices (types GOV2, IGV1); still reportable under 43243
4. Injection Technique — The sclerosant is delivered via an endoscopic injection needle, either:
   • Intravariceal: directly into the variceal lumen (preferred; causes intraluminal thrombosis)
   • Paravariceal: adjacent to the varix in the submucosa (causes perivariceal fibrosis and compression)
5. Endpoint — Thrombosis, mucosal blanching, and variceal obliteration; hemostasis achieved if hemorrhage was active.

💡 Clinical Context: Injection sclerotherapy (43243) has been largely superseded by band ligation (43244) for primary and secondary prophylaxis of esophageal variceal hemorrhage due to band ligation’s superior safety profile and lower rebleeding rates per current AASLD and Baveno VII guidelines. However, sclerotherapy remains clinically relevant in active hemorrhage with poor visualization, anatomically inaccessible varices, gastric varices not amenable to banding, pediatric patients, and resource-limited settings. ^{Baveno VII 2022 · AASLD Portal HTN Guidelines}

---

✅ Includes (Bundled Components)

The following services are inherent to 43243 and must not be separately reported:

• Full diagnostic examination of the esophagus, stomach, and duodenum/proximal jejunum
• Moderate (conscious) sedation — per CPT guidelines, sedation is bundled into all EGD codes; do not report 99152 or 99153 separately unless performed by an independent provider
• Injection of one or more sclerosant agents at single or multiple variceal sites during the same session
• Standard endoscopic photography and procedural documentation
• Routine preparation, scope introduction, and scope withdrawal
• Endoscopic irrigation or suctioning performed incidentally

---

❌ Excludes / Mutually Exclusive Codes

Code	Description	Reason Excluded
43235	Diagnostic EGD (base code)	Inherent — bundled per NCCI; the diagnostic exam is part of all therapeutic EGDs
43239	EGD with injection, other than sclerotherapy	Mutually exclusive — different injection type (e.g., epinephrine); cannot combine
43244	EGD with band ligation of esophageal/gastric varices	Cannot bill both sclerotherapy and band ligation for the same varices in the same session
43255	EGD with control of bleeding, any method	Bundled via NCCI — hemorrhage control is inherent to sclerotherapy of actively bleeding varices
99152 / 99153	Moderate sedation services	Sedation bundled; report only if performed by a separate, independent provider
76000	Fluoroscopy	Incidental fluoroscopy is not separately reportable

⚠️ NCCI Reminder: CMS NCCI column I/II edits bundle 43235 into 43243. If a separate, distinct diagnostic EGD was medically necessary at a prior encounter, it may be separately reportable with appropriate documentation. Do not unbundle same-session diagnostic and therapeutic EGD services. ^{CMS NCCI Policy Manual, Ch. 9}

---

🌳 Code Tree — EGD Family (43235-43270)

43235 ─── Diagnostic EGD (BASE CODE — all therapeutic EGDs include this component)
│
├── 43236 ─── with directed submucosal injection(s), any substance
├── 43237 ─── with endoscopic ultrasound examination (esophagus only)
├── 43238 ─── with EUS-guided FNA/biopsy (esophagus)
├── 43239 ─── with injection, other than sclerotherapy (e.g., epinephrine, BOTOX)
│
├── 43243 ─── with injection sclerotherapy of esophageal/gastric varices  ◀ THIS CODE
├── 43244 ─── with band ligation of esophageal/gastric varices
│
├── 43245 ─── with dilation of gastric/duodenal stenosis
├── 43246 ─── with directed submucosal injection(s)
├── 43247 ─── with removal of foreign body(s)
├── 43248 ─── with insertion of guide wire followed by dilation of esophagus
├── 43249 ─── with balloon dilation of esophagus (<30 mm diameter)
│
├── 43250 ─── with removal of tumor/polyp(s) by hot biopsy forceps
├── 43251 ─── with removal of tumor/polyp(s) by snare technique
├── 43252 ─── with optical endomicroscopy
├── 43253 ─── with EUS-guided intramural or transmural FNA/biopsy (stomach/duodenum)
├── 43254 ─── with endoscopic mucosal resection (EMR)
├── 43255 ─── with control of bleeding, any method
│
├── 43257 ─── with delivery of thermal energy to lower esophageal sphincter/gastric cardia (GERD)
├── 43259 ─── with endoscopic ultrasound examination, including duodenum
└── 43270 ─── with ablation of tumor(s)/polyp(s)/other lesion(s), not amenable to removal

---

🏷️ Associated ICD-10-CM Codes

Primary Diagnoses

ICD-10-CM	Description	HCC (v28)	HCC Category	Notes
I85.01	Esophageal varices with bleeding	✅ HCC 29	Chronic Liver Disease & Cirrhosis	High-risk HCC; document underlying cause
I85.00	Esophageal varices without bleeding	✅ HCC 29	Chronic Liver Disease & Cirrhosis	Use for prophylactic/elective sessions
I85.11	Secondary esophageal varices with bleeding	✅ HCC 29	Chronic Liver Disease & Cirrhosis	Secondary = caused by portal HTN from liver disease
I85.10	Secondary esophageal varices without bleeding	✅ HCC 29	Chronic Liver Disease & Cirrhosis
I86.4	Gastric varices	⚠️ No direct HCC	—	Code underlying cause separately

Common Secondary / Etiology Codes

ICD-10-CM	Description	HCC (v28)	Notes
K70.30	Alcoholic cirrhosis of liver without ascites	✅ HCC 29	Sequence after variceal code
K70.31	Alcoholic cirrhosis of liver with ascites	✅ HCC 29	Ascites documented? Code it
K74.60	Unspecified cirrhosis of liver	✅ HCC 29	Use only when etiology undocumented
K74.61	Primary biliary cirrhosis	✅ HCC 29
K74.69	Other cirrhosis of liver	✅ HCC 29
B18.2	Chronic viral hepatitis C	✅ HCC 29	When HCV-related cirrhosis documented
B18.1	Chronic viral hepatitis B without delta agent	✅ HCC 29
K76.6	Portal hypertension	❌ No HCC	Add when explicitly documented
K92.0	Hematemesis	❌ No HCC	Active upper GI bleed symptoms
K92.1	Melena	❌ No HCC

HCC Mapping Notes (CMS v28 Model)

💡 HCC 29 — Chronic Liver Disease & Cirrhosis carries significant risk adjustment weight under the CMS-HCC v28 model. Esophageal varices (especially with hemorrhage) map to this category and reflect high disease burden and resource utilization. As an inpatient coder, ensure the underlying hepatic etiology (alcoholic cirrhosis, viral hepatitis-related cirrhosis, etc.) is captured and coded in addition to the variceal complication. Incomplete capture of the root etiology = missed HCCs = underpayment risk for the facility under value-based payment models. ^{CMS HCC Model v28 Mappings · ICD-10-CM FY2026 Guidelines}

---

🏥 MS-DRG Mapping (Inpatient Context)

Inpatient Coder Note: CPT codes are not used in the inpatient setting. MS-DRG assignment is driven by ICD-10-PCS procedure codes and ICD-10-CM diagnoses. The table below reflects DRGs commonly assigned when the patient’s principal diagnosis is esophageal/gastric varices or related hepatic pathology with an endoscopic procedure performed.

Hepatic/Variceal DRGs (MDC 07)

MS-DRG	Description	Typical GMLOS
441	Disorders of Liver except Malignancy, Cirrhosis, Alcoholic Hepatitis w MCC	~7.0 days
442	Disorders of Liver except Malignancy, Cirrhosis, Alcoholic Hepatitis w CC	~4.0 days
443	Disorders of Liver except Malignancy, Cirrhosis, Alcoholic Hepatitis w/o CC/MCC	~2.5 days

GI Hemorrhage DRGs (MDC 06)

MS-DRG	Description	Typical GMLOS
377	GI Hemorrhage w MCC	~5.5 days
378	GI Hemorrhage w CC	~3.5 days
379	GI Hemorrhage w/o CC/MCC	~2.3 days

⚠️ DRG Optimization Tip: If the patient has both cirrhosis and active variceal hemorrhage, the principal diagnosis assignment between I85.01 vs. K70.30/K74.60 can affect whether the case groups to MDC 07 (hepatic DRGs 441-443) or MDC 06 (GI hemorrhage DRGs 377-379). Review the UHDDS principal diagnosis definition and physician documentation carefully. Neither choice is “wrong” if it reflects the circumstances of the admission, but the distinction carries DRG payment weight differences.

---

🔩 ICD-10-PCS Crosswalk (Inpatient Procedure Coding)

The following ICD-10-PCS codes represent the endoscopic sclerotherapy of esophageal or gastric varices in the inpatient setting.

Root Operation Guidance

Root Operation	Definition	When to Use for Sclerotherapy
Occlusion (L)	Completely closing an orifice or lumen	Preferred when intent is to obliterate/close the variceal channel
Destruction (5)	Physical eradication of body part	Use when documentation emphasizes destruction/ablation of variceal tissue

💡 Query the physician if documentation does not clearly distinguish intent. AHA Coding Clinic guidance should be consulted for facility-specific direction. ^{AHA Coding Clinic}

Esophageal Varices — Sclerotherapy

Component	Value	Code Character
Section	Medical and Surgical	0
Body System	Lower Veins	6
Root Operation	Occlusion	L
Body Part	Esophageal Vein	3
Approach	Via Natural or Artificial Opening Endoscopic	8
Device	No Device	Z
Qualifier	No Qualifier	Z
Full PCS Code	Occlusion of Esophageal Vein, Endoscopic	06L38ZZ

Component	Value	Code Character
Root Operation	Destruction	5
Body Part	Esophageal Vein	3
Approach	Via Natural or Artificial Opening Endoscopic	8
Full PCS Code	Destruction of Esophageal Vein, Endoscopic	06538ZZ

Gastric Varices — Sclerotherapy

Component	Value	Code Character
Body System	Lower Veins	6
Root Operation	Occlusion	L
Body Part	Gastric Vein	2
Approach	Via Natural or Artificial Opening Endoscopic	8
Full PCS Code	Occlusion of Gastric Vein, Endoscopic	06L28ZZ

---

🏷️ Applicable Modifiers

Modifier	Name	Application to 43243
-22	Increased Procedural Services	Document why the procedure required substantially more time/effort (e.g., multiple large variceal columns, difficult anatomy, repeated injections); attach operative report
-52	Reduced Services	Procedure initiated but only partially completed (e.g., patient became unstable mid-scope, only partial treatment rendered)
-53	Discontinued Procedure	Procedure terminated after anesthesia/sedation administered but before therapeutic injection began due to patient safety concern
-59	Distinct Procedural Service	Use cautiously per NCCI guidelines if a separate, distinct GI procedure was medically necessary at the same session (e.g., 43255 for unrelated bleeding site)
-XU	Unusual Non-Overlapping Service	CMS preferred alternative to -59 for distinct service documentation on same date
-47	Anesthesia by Surgeon	Rarely applicable; use only if the performing surgeon personally administers general anesthesia (not moderate sedation, which is bundled)
-GC	Teaching Physician Service	Academic/teaching hospital settings where a resident participates under attending supervision
-GE	Resident Service Without Supervising Physician	Used under Medicare primary care exception (limited applicability for this procedure)

---

📝 Coding Examples

Example 1 — Emergency: Active Esophageal Variceal Hemorrhage, Alcoholic Cirrhosis

Scenario: A 52-year-old male with known alcoholic cirrhosis and ascites presents to the ED with massive hematemesis. Emergent EGD reveals Grade III esophageal varices with active spurting hemorrhage. Injection sclerotherapy with sodium morrhuate is performed with successful hemostasis. Anesthesia administered by CRNA independently.

Professional/Outpatient Billing:

• 43243 — EGD with injection sclerotherapy (primary procedure)

ICD-10-CM:

• I85.01 — Esophageal varices with bleeding (principal)
• K70.31 — Alcoholic cirrhosis with ascites (secondary)

Inpatient ICD-10-PCS:

• 06L38ZZ — Occlusion of Esophageal Vein, Via Natural or Artificial Opening Endoscopic

MS-DRG: 441 (Disorders of Liver w MCC, if MCC documented) or 377 (GI Hemorrhage w MCC)

---

Example 2 — Prophylactic Sclerotherapy, Non-Bleeding Varices, HCV Cirrhosis

Scenario: Patient with hepatitis C-related cirrhosis (no current bleeding) presents for elective surveillance EGD. Grade II esophageal varices identified. Prophylactic injection sclerotherapy performed with ethanolamine oleate to reduce future hemorrhage risk.

Professional/Outpatient Billing:

• 43243 — EGD with injection sclerotherapy

ICD-10-CM:

• I85.00 — Esophageal varices without bleeding (primary)
• B18.2 — Chronic viral hepatitis C (secondary)
• K74.69 — Other cirrhosis (secondary, if documented)

MS-DRG (if inpatient): 442 or 443 depending on CC/MCC status

---

Example 3 — Gastric Varices, Cyanoacrylate Glue Injection

Scenario: Patient with portal hypertension and fundal gastric varices (Sarin IGV1 type) undergoes EGD with cyanoacrylate glue injection sclerotherapy for obliteration of gastric varices.

Professional/Outpatient Billing:

• 43243 — EGD with injection sclerotherapy (cyanoacrylate glue injection of gastric varices is still classified as sclerotherapy)

ICD-10-CM:

• I86.4 — Gastric varices (primary)
• K76.6 — Portal hypertension (secondary)

Inpatient ICD-10-PCS:

• 06L28ZZ — Occlusion of Gastric Vein, Via Natural or Artificial Opening Endoscopic

⚠️ Coding Note: Cyanoacrylate glue is a sclerosing/occluding agent. Even though it differs mechanistically from traditional liquid sclerosants, it is correctly reported under 43243 when the approach is endoscopic injection for variceal obliteration. No separate CPT exists for cyanoacrylate EGD injection.

---

Example 4 — Attempted Sclerotherapy, Converted to Band Ligation Same Session

Scenario: Endoscopist begins injection sclerotherapy of esophageal varices but encounters technical difficulty. Procedure is converted intraoperatively to band ligation, which is successfully completed.

Coding Guidance:

• Report only 43244 (band ligation) — the definitive, completed procedure
• Do not additionally report 43243 — an incomplete attempt that is abandoned mid-procedure and converted does not constitute a separately billable service
• If the procedure was unusually complex or time-consuming, append Modifier -22 with supporting operative documentation
• If sclerotherapy was fully completed at one variceal column AND band ligation was subsequently performed at a distinct, separate variceal site, query the physician and consult NCCI edits and payer policy before billing both

---

Example 5 — Inpatient Admission, GI Bleed Workup, Modifier GC Applicable

Scenario: Teaching hospital. Patient admitted for acute GI bleed; EGD with sclerotherapy performed by GI fellow under direct supervision of attending gastroenterologist. Attending documents presence, personal participation, and key portions of the procedure.

Professional Billing:

• 43243--GC — Teaching physician attestation satisfies Medicare requirements

---

⚙️ Billing & Reimbursement Notes

• Medicare Coverage: No current National Coverage Determination (NCD) specifically governs 43243; coverage is adjudicated by the applicable MAC per LCD or contractor policy. Medical necessity documentation (indication, variceal grade, hemorrhage status) is essential.
• Place of Service (POS): Commonly billed under:
  • POS 22 — Hospital Outpatient
  • POS 24 — Ambulatory Surgical Center (ASC)
  • POS 21 — Inpatient Hospital (professional component)
• Facility vs. Non-Facility RVUs: Facility RVU total is lower than non-facility total. Confirm the applicable rate against the current CMS PFS for the correct reimbursement calculation. Physician RVU totals differ between facility and non-facility settings.
• Same-Day Diagnostic EGD Rule: If the endoscopist performed a diagnostic EGD (43235) and immediately proceeded to sclerotherapy in the same session, report only 43243. The diagnostic component is inherent and must not be separately billed on the same date.
• Anesthesia Considerations: If the procedure is performed under general anesthesia administered by an anesthesiologist (rather than moderate sedation), the anesthesiologist bills separately using the applicable anesthesia CPT code. The performing endoscopist does not additionally report 99152.
• Unlisted Code Alternative: If an endoscopic technique not fully described by any CPT code is used (rare), 43499 (unlisted procedure, esophagus) may be considered with prior authorization and supporting documentation.

---

🔗 Related Codes & Cross-References

Code	Description	Relationship
43235	Diagnostic EGD	Base code; bundled into 43243
43239	EGD with injection, other than sclerotherapy	Alternate injection type (epinephrine, BOTOX)
43244	EGD with band ligation of varices	Preferred alternative to sclerotherapy per current guidelines
43255	EGD with control of bleeding, any method	Bundled per NCCI when same variceal bleeding site
43270	EGD with ablation of lesions	Ablation of non-variceal lesions
37241	Vascular embolization or occlusion	Radiologic/interventional approach (non-endoscopic); used for TIPS or coil embolization
43460	Esophagogastric tamponade with balloon	Used when endoscopy fails or unavailable (Blakemore/Minnesota tube)
I85.01	Esophageal varices with bleeding	Primary diagnosis — most common indication
I86.4	Gastric varices	Primary diagnosis — gastric variceal sclerotherapy
K70.31	Alcoholic cirrhosis with ascites	Most common underlying etiology in U.S.
06L38ZZ	Occlusion of Esophageal Vein, Endoscopic	ICD-10-PCS inpatient equivalent — Occlusion
06538ZZ	Destruction of Esophageal Vein, Endoscopic	ICD-10-PCS inpatient equivalent — Destruction

---

^{AMA CPT 2026 Professional Edition · CMS Physician Fee Schedule 2026 Final Rule · CMS NCCI Policy Manual v32 · ICD-10-CM Official Guidelines for Coding and Reporting FY2026 · ICD-10-PCS Official Guidelines FY2026 · CMS-HCC Risk Adjustment Model v28 · AHA Coding Clinic for ICD-10-CM/PCS · Baveno VII Consensus on Portal Hypertension 2022 · AASLD Practice Guidance: Portal Hypertensive Bleeding · Garcia-Tsao G et al., Hepatology 2022}