43255

⚕️CPT Code 43255 — EGD with Control of Bleeding, Any Method

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📋 Official Code Descriptor

Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method

"Any Method" — What This Means

The phrase “any method” is clinically and legally significant. The specific hemostatic technique — whether clips, argon plasma coagulation (APC), bipolar cautery, heater probe, epinephrine injection, or any combination — does not change the CPT code. 43255 is the correct code regardless of technique used, as long as active control of bleeding was performed as the primary or secondary therapeutic goal of the endoscopy. The method does need to be documented in the procedure note for medical necessity and compliance purposes, but it does not escalate or change the billing code._{AMA CPT Professional Edition 2025; ASGE Coding Guide 2024}

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🧠 Clinical Overview

What Is an EGD?

An esophagogastroduodenoscopy (EGD) is a flexible, transoral endoscopic examination of the upper gastrointestinal tract from the cricopharyngeus (esophageal inlet) to the second portion of the duodenum (D2). Using a fiberoptic or video endoscope, the physician directly visualizes the:

• Esophagus — all three segments (proximal, mid, distal) and the gastroesophageal junction (GEJ)
• Stomach — cardia, fundus, body, antrum, and pylorus (retroflexed view of fundus/cardia)
• Duodenum — bulb (D1) and second portion (D2) including the ampulla of Vater

The Therapeutic Indication — Control of Bleeding

CPT 43255 is a therapeutic EGD — the physician is not merely visualizing the GI tract but actively intervening to stop active hemorrhage. The procedure begins with diagnostic visualization to identify the bleeding source, followed immediately by the hemostatic intervention. The diagnostic component (43235) is inherently included and not separately reportable.

Common sources of upper GI bleeding treated with 43255:

Etiology	Common Location	Typical Method
Peptic ulcer — gastric	Stomach, lesser curvature	Epinephrine injection + APC or clip
Peptic ulcer — duodenal	Duodenal bulb (D1)	Epinephrine injection + clip
Dieulafoy lesion	Gastric body (proximal)	Endoclip; APC; injection
Mallory-Weiss tear	Gastroesophageal junction	APC; injection; clip
Cameron lesion	Hiatal hernia sac	APC; coagulation
Angiodysplasia / AVM	Stomach, duodenum	APC thermal ablation
Post-polypectomy bleeding	Stomach or duodenum	Clip; APC; injection
Post-EMR bleeding	Stomach (post-resection bed)	Clip; APC
GAVE (watermelon stomach)	Antrum	APC — typically multiple sessions

Esophageal and Gastric VARICES — These Are NOT 43255

Per CPT parenthetical instructions added in the 2014 code revision cycle, 43255 should not be reported for the treatment of esophageal or gastric varices. Variceal hemorrhage has dedicated, more specific codes:

• 43243 — EGD with injection of esophageal varices (sclerotherapy)
• 43244 — EGD with band ligation of esophageal varices (EVL)

Using 43255 for variceal hemorrhage is a coding error that misrepresents the procedure and constitutes a compliance risk. The clinical record drives the distinction: if the endoscopy report documents “varices” as the bleeding source with treatment, use 43243 or 43244 — not 43255._{AGA CPT Advisors 2014; AMA CPT Professional Edition 2025}

Hemostatic Techniques in Detail

1. Endoscopic Hemostatic Clips (Endoclips) Mechanical clips are deployed through the endoscope to approximate vessel walls or pinch bleeding tissue, mechanically stopping blood flow. Modern clips include Resolution 360°, Instinct, and OTSC (over-the-scope clip). Clip placement is appropriate for Forrest Ia, Ib, and IIa ulcers.

2. Argon Plasma Coagulation (APC) A non-contact thermal modality delivering high-frequency monopolar current through ionized argon gas. Ideal for flat, diffuse lesions — angiodysplasias, GAVE (watermelon stomach), Cameron lesions, and post-ablation bleeding. Depth of penetration is controlled (0.5-3 mm), minimizing perforation risk.

3. Bipolar Electrocoagulation (BICAP / Gold Probe) Contact thermal coagulation using a bipolar probe pressed against the bleeding vessel with firm tamponade, then activating cautery. The gold standard for Dieulafoy lesions and visible vessels (Forrest IIa).

4. Heater Probe An aluminum-coated probe that delivers controlled heat via direct tissue contact. Effective for ulcer-related bleeding with visible vessels.

5. Epinephrine Injection Dilute epinephrine (1:10,000 or 1:20,000) is injected submucosally around the bleeding vessel to cause local vasoconstriction and tissue tamponade. Always used as a first-line adjunct — never as monotherapy per current society guidelines. Combined with a second mechanical or thermal modality for definitive hemostasis._{ACG Clinical Guideline: UGIB 2021; ESGE Upper GI Bleeding Guideline 2021}

6. Combination Therapy Current ACG/ASGE guidelines recommend dual-modality therapy for high-risk lesions (actively bleeding ulcers, visible vessels) — e.g., epinephrine injection followed by clip or thermal coagulation. Regardless of how many methods are used in a single session, only one 43255 is reported.

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💰 Fee Schedule & Valuation

Field	Value
wRVU	3.56 (verify vs. current CMS MPFS Addendum B each fiscal year)
Global Period	000 days
Assistant Surgeon Payable	❌ Not payable (endoscopic procedures)
Co-Surgery Payable	❌ Not applicable
Team Surgery Payable	❌ Not applicable
Bilateral Surgery Reduction	❌ Not applicable
Multiple Procedure Reduction	✅ Applies — Multiple Endoscopy Rule governs (see below)
Modifier 51 Exempt	❌ No
Medicare Status Indicator	Active — payable
ASC APC (2026)	APC 5302 — ~$1,960 (facility payment)
Complexity Adjustment APC	APC 5303 (~$3,939) when billed with 43254

The Multiple Endoscopy Rule — Critical for 43255

CMS applies a multiple endoscopy rule when two or more codes from the same endoscopic family are billed together for the same encounter. The rule works as follows:

Full payment is made for the highest-valued procedure. For any additional endoscopic procedure from the same family, Medicare pays the difference between that procedure’s fee and the fee for the base diagnostic code (43235).

Formula:

Payment for additional endo procedure =
  [Fee for additional procedure] - [Fee for base code 43235]

Practical Example: If 43251 (snare polypectomy, ~3.80 wRVU) and 43255 (control of bleeding, ~3.56 wRVU) are both performed at the same session:

• Report 43251 as primary (higher wRVU)
• Report 43255 as secondary
• Medicare pays 43255 at its fee minus the 43235 base fee
• This typically results in a low or near-zero additional payment for the secondary code

Modifier 59 and the Multiple Endoscopy Rule

Unlike most NCCI edits, appending modifier -59 to unbundle same-family EGD codes is not appropriate unless the procedures were truly performed in separate sessions (e.g., morning and evening EGDs) or on distinctly separate anatomic body systems. Do not use -59 merely to receive full payment for both endoscopic codes within the same session — this is an NCCI violation.

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🌳 Code Tree — EGD Family (43235-43270) — Therapeutic Tier

Foundational Rule — Surgical Endoscopy Includes Diagnostic

CPT guidelines state that a surgical (therapeutic) endoscopy always includes the diagnostic endoscopy. This means 43235 (diagnostic EGD) is never separately reported on the same day as 43255 or any other therapeutic EGD code. Report only the single highest-complexity code that represents all work performed.

EGD Family — Therapeutic Procedures (43235-43270)
│
├── 43235 — Diagnostic EGD only (base/parent code for the endoscopy family)
│       ↳ Visualization only; brushings or washings (no tissue removal)
│       ↳ wRVU: ~2.61 | Endo base code — NEVER report with any therapeutic code below
│
├── 43236 — EGD with directed submucosal injection(s)
│       ↳ e.g., botulinum toxin, tattooing, submucosal lifting
│
├── 43239 — EGD with biopsy, single or multiple
│       ↳ Tissue removal via forceps
│
├── 43243 — EGD with injection of esophageal varices
│       ↳ Sclerotherapy for variceal hemorrhage — NOT 43255
│
├── 43244 — EGD with band ligation of esophageal varices
│       ↳ Variceal band ligation (EVL) — NOT 43255
│
├── 43247 — EGD with foreign body removal
│       ↳ Retrieval devices; nets; forceps
│
├── 43249 — EGD with balloon dilation, esophagus or pylorus (<30mm)
│       ↳ Stricture dilation
│
├── 43250 — EGD with removal of lesion by hot biopsy or bipolar cautery
│       ↳ Small polyp destruction; thermal technique
│
├── 43251 — EGD with removal of lesion(s) by snare technique
│       ↳ Snare polypectomy — cold or hot
│
├── 43254 — EGD with endoscopic mucosal resection (EMR)
│       ↳ En bloc or piecemeal submucosal resection
│       ↳ When combined with 43255 → APC complexity adjustment (APC 5303)
│
├── 43255 — EGD with control of bleeding, any method ✅ (THIS CODE)
│       ↳ Clips, APC, bipolar, heater probe, injection, or combination
│       ↳ wRVU: 3.56 | NOT for varices
│
├── 43266 — EGD with endoscopic stent placement
│       ↳ Esophageal or duodenal stent for obstruction/palliation
│
└── 43270 — EGD with ablation of lesion(s)
        ↳ RFA, APC for Barrett's esophagus, GAVE, lesions
        ↳ Includes pre/post-dilation and guide wire passage

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✅ Included in 43255 (Bundled — Do NOT Report Separately)

• Passage of the endoscope from mouth to second portion of duodenum (D2)
• Complete diagnostic visualization of the esophagus, stomach, and duodenum
• Identification and localization of the bleeding source
• All hemostatic interventions performed during the same endoscopic session, regardless of technique or number of passes
• Multiple applications of the same device (e.g., multiple clips placed at the same or different sites during the same endoscopy)
• Multiple applications of different hemostatic devices (e.g., epinephrine injection followed by APC followed by clip)
• Irrigation and washing of the mucosal surface to clear blood and identify the bleeding site
• Post-hemostasis inspection and documentation of hemostasis
• Routine moderate sedation/monitoring (if provided by same physician — see Sedation note below)

Sedation Billing — Same Physician

If the same physician who performs 43255 also provides moderate sedation, Medicare requires reporting of G0500 (first 15 minutes) and 99153 for each additional 15 minutes. An independent trained observer must be present and documented. For commercial payers, 99152 + 99153 are typically used instead. If a separate anesthesia professional (CRNA, anesthesiologist) provides MAC or general anesthesia, anesthesia codes are billed by that provider separately; the performing physician bills 43255 only.

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❌ Excludes / Do Not Report With 43255

Code	Description	Reason
43235	Diagnostic EGD only	Bundled — surgical endoscopy includes diagnostic; do not stack
43236	EGD with submucosal injection(s)	If injection is purely hemostatic → 43255; if for marking/Botox → 43236
43243	EGD with injection of esophageal varices	Variceal bleeding must use 43243 — not 43255
43244	EGD with band ligation of esophageal varices	Variceal band ligation must use 43244 — not 43255
43239	EGD with biopsy	When performed together, apply multiple endoscopy rule; do NOT add 43235
43254	EGD with EMR	Separately reportable in same session; 43255 + 43254 → APC complexity adjustment
43270	EGD with ablation of lesion	APC for ablation of Barrett’s → 43270; APC to stop bleeding → 43255
99213-99215	E/M services, same day	Same-day E/M by the same physician is not separately billable for work within the 000-day global unless it is a significant, separately identifiable service (append 25 if applicable and well-documented)

43255 is NOT Appropriate for Minor Post-Polypectomy Ooze

Minor oozing that occurs as an expected consequence of a polyp removal (43251) or EMR (43254) is integral to the therapeutic procedure and not separately reported as 43255. To report 43255 in addition to a polypectomy or resection code, the bleeding must be:

1. A distinct, significant bleeding event (not minor post-procedure ooze)
2. Requiring a separate, distinct therapeutic intervention beyond the standard post-resection care
3. Clearly documented as such in the procedure note

Reflexive addition of 43255 to every polypectomy claim without documentation of a distinct significant bleed is a known OIG audit area and NCCI compliance risk._{BellMedEx EGD Coding Guide 2025; AAPC Forum guidance}

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🔧 Modifiers

Modifier	Name	When to Use with 43255
-22	Increased Procedural Services	Exceptionally difficult hemostasis: severe coagulopathy, massive hemorrhage, multiple simultaneous bleeding sites, unusual anatomy, or documented failure of first-line hemostasis requiring escalated therapy in the same session; must attach operative documentation explaining the substantial additional work
-26	Professional Component	When 43255 is billed by the interpreting/performing physician in a facility setting where the technical component is billed separately by the facility — relatively uncommon for endoscopy (usually global billing)
-52	Reduced Services	Procedure initiated but completed to a lesser extent (e.g., unable to reach duodenum due to blood obscuring view; partial hemostasis only); rarely used for 43255
-53	Discontinued Procedure	Procedure started but terminated prematurely due to patient safety concern (e.g., hemodynamic instability requiring emergent termination); scope was inserted and service began
-59	Distinct Procedural Service	Use with extreme caution in the EGD family — only appropriate when 43255 is performed in a genuinely separate session from another EGD on the same date, not merely to bypass the multiple endoscopy rule
-76	Repeat Procedure, Same Physician	Second EGD for bleeding control on the same date of service by the same physician (e.g., morning EGD with hemostasis, return to OR same day for re-bleeding)
-77	Repeat Procedure, Different Physician	Second EGD for bleeding control on the same date by a different physician
-78	Unplanned Return to Endoscopy Suite	EGD performed for re-bleeding complication within the 000-day global period (same day); appended to the repeat 43255
-79	Unrelated Procedure in Global Period	Not applicable given the 000-day global — by definition there is no postoperative period
-XS	Separate Structure (X-modifier)	CMS-preferred alternative to -59 for claims requiring a distinct body structure justification; applies only when truly separate anatomic sites

Modifier 76 for Same-Day Repeat EGD

A common real-world scenario: a patient undergoes emergent EGD at 2:00 AM for hematemesis with gastric ulcer hemorrhage — clips applied, bleeding controlled. The patient re-bleeds at 6:00 PM the same calendar day. Repeat EGD is performed. Report: 43255-76 for the repeat procedure. Document that this is a new bleeding episode requiring a second intervention.

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🩺 Commonly Associated ICD-10-CM Diagnosis Codes

HCC Applicability

The ICD-10-CM diagnosis codes typically paired with CPT 43255 are acute hemorrhagic conditions, peptic ulcer disease with hemorrhage, and related GI pathology. Under the current CMS-HCC v28 model, none of the primary GI hemorrhage or ulcer-with-hemorrhage codes carry HCC risk-adjustment mapping. HCC is annotated as Not HCC throughout this section.

Peptic Ulcer Disease with Hemorrhage — Highest Specificity (Assign When Source Confirmed)

ICD-10-CM	Description	HCC
K25.0	Acute gastric ulcer with hemorrhage	Not HCC
K25.2	Acute gastric ulcer with both hemorrhage and perforation	Not HCC
K25.4	Chronic or unspecified gastric ulcer with hemorrhage	Not HCC
K25.6	Chronic or unspecified gastric ulcer with both hemorrhage and perforation	Not HCC
K26.0	Acute duodenal ulcer with hemorrhage	Not HCC
K26.2	Acute duodenal ulcer with both hemorrhage and perforation	Not HCC
K26.4	Chronic or unspecified duodenal ulcer with hemorrhage	Not HCC
K26.6	Chronic or unspecified duodenal ulcer with both hemorrhage and perforation	Not HCC
K27.0	Acute peptic ulcer, site unspecified, with hemorrhage	Not HCC
K27.4	Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage	Not HCC
K28.0	Acute gastrojejunal ulcer with hemorrhage	Not HCC
K28.4	Chronic or unspecified gastrojejunal ulcer with hemorrhage	Not HCC

Specificity Sequencing Rule for Peptic Ulcer

Per ICD-10-CM Official Guidelines, when a patient is admitted for hemorrhage due to peptic ulcer disease, the ulcer with hemorrhage code (e.g., K25.4) is the principal diagnosis — not the symptom codes K92.0 or K92.1. Symptom codes (hematemesis, melena) should be dropped when the etiology is confirmed, as they are integral to the “with hemorrhage” combination code._{ICD-10-CM Official Guidelines FY2026, Section I.C.9}

Gastritis with Hemorrhage

ICD-10-CM	Description	HCC
K29.01	Acute gastritis with bleeding	Not HCC
K29.71	Gastritis, unspecified, with bleeding	Not HCC

Angiodysplasia / Vascular Malformation

ICD-10-CM	Description	HCC
K31.811	Angiodysplasia of stomach and duodenum with bleeding	Not HCC

Mallory-Weiss Tear

ICD-10-CM	Description	HCC
K22.6	Gastro-esophageal laceration-hemorrhage syndrome (Mallory-Weiss)	Not HCC

Post-Procedural Hemorrhage (Post-EMR, Post-Polypectomy)

ICD-10-CM	Description	HCC
K91.840	Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure	Not HCC
K91.841	Postprocedural hemorrhage of a digestive system organ or structure following other procedure	Not HCC

Nonspecific GI Hemorrhage (Use When Source Not Yet Confirmed at Time of Coding)

ICD-10-CM	Description	HCC
K92.0	Hematemesis	Not HCC
K92.1	Melena	Not HCC
K92.2	Gastrointestinal hemorrhage, unspecified	Not HCC

K92.2 — Use as Last Resort

K92.2 (GI hemorrhage, unspecified) is appropriate only when endoscopy has been performed and the source remains genuinely undetermined at the time of coding, or when the clinical record does not support a more specific diagnosis. It should NOT be used routinely when a specific cause (e.g., gastric ulcer, Mallory-Weiss tear) was identified during the EGD that prompted 43255. Using K92.2 when a more specific ulcer-with-hemorrhage code is supported by documentation is undercoding and affects DRG weight, reimbursement, and quality data accuracy._{ICD-10-CM Official Guidelines FY2026}

Associated Secondary Diagnoses

ICD-10-CM	Description	HCC
D62	Acute posthemorrhagic anemia	Not HCC
D50.0	Iron deficiency anemia secondary to blood loss (chronic)	Not HCC
B18.2	Chronic viral hepatitis C	Not HCC
K74.60	Unspecified cirrhosis of liver	HCC 27 (if cirrhosis documented — triggers HCC mapping; sequence carefully)
Z79.01	Long-term (current) use of anticoagulants	Not HCC
Z79.02	Long-term (current) use of antithrombotics/antiplatelets	Not HCC

Anticoagulation / Antiplatelet Drug-Induced Bleed

When GI hemorrhage is drug-induced (e.g., warfarin, aspirin, NSAIDs, NOACs), code both the GI condition with hemorrhage AND an adverse effect code from the T36-T50 range to capture the causative drug. Additionally, append Z79.01 (anticoagulants) or Z79.02 (antithrombotics) as appropriate. This documentation supports medical necessity, DRG complexity, and risk stratification data.

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🏥 ICD-10-PCS Equivalents (Inpatient Facility Coding)

Inpatient Coding Note

In the inpatient hospital setting, CPT codes are never used for facility billing. Assign ICD-10-PCS procedure codes. 43255 maps to the Control root operation in ICD-10-PCS, reflecting the operative intent of stopping acute bleeding. Alternatively, specific GI body-system Repair codes may apply if the operative context is restoration of a damaged mucosal structure.

Root Operation: Control (3) — Primary PCS Root Operation for 43255

ICD-10-PCS defines Control as: “Stopping, or attempting to stop, postprocedural or other acute bleeding.” This precisely maps to the clinical intent of 43255.

Anatomical Regions, General (Body System W) — When Source Is Not Isolated to One Organ

ICD-10-PCS	Description	Characters
0W3G8ZZ	Control Gastrointestinal Tract, Via Natural or Artificial Opening Endoscopic	0=Med/Surg; W=Anat Region; 3=Control; G=GI Tract; 8=Endoscopic; Z=No Device; Z=No Qualifier

Gastrointestinal System (Body System D) — When Specific Organ Is Documented

ICD-10-PCS	Description	Notes
0D358ZZ	Control Esophagus, Via Natural or Artificial Opening Endoscopic	Esophageal bleeding source (e.g., Mallory-Weiss)
0D368ZZ	Control Stomach, Via Natural or Artificial Opening Endoscopic	Gastric ulcer / angiodysplasia / GAVE
0D398ZZ	Control Duodenum, Via Natural or Artificial Opening Endoscopic	Duodenal ulcer source

Organ-Specific vs. GI Tract NOS

When the operative/endoscopy note clearly identifies the specific organ as the source of bleeding (e.g., “bleeding gastric ulcer on lesser curvature — treated with clips”), assign the organ-specific code (e.g., 0D368ZZ for stomach). Reserve 0W3G8ZZ (GI Tract) for cases where the bleed spans multiple segments or the specific organ is genuinely unspecified in documentation._{ICD-10-PCS Official Guidelines FY2026, Guideline B4.3}

Root Operation: Repair (Q) — When Mucosal Integrity Restoration Is the Primary Objective

If the procedure note describes restoration of lacerated or disrupted GI mucosa (e.g., large Mallory-Weiss tear with active bleeding repaired by clips to restore structural integrity):

ICD-10-PCS	Description
0DQ58ZZ	Repair Esophagus, Via Natural or Artificial Opening Endoscopic
0DQ68ZZ	Repair Stomach, Via Natural or Artificial Opening Endoscopic
0DQ98ZZ	Repair Duodenum, Via Natural or Artificial Opening Endoscopic

Control vs. Repair — Root Operation Selection

Per PCS guidelines, Control (3) is used when the sole objective is to stop hemorrhage. Repair (Q) is used when the objective is to restore mucosal/structural anatomy. In most EGD hemostasis scenarios, Control is the appropriate root operation. Use Repair only when documentation explicitly describes mucosal repair as the primary goal.

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🏨 MS-DRG Assignment

Inpatient DRG Note

MS-DRG assignment is driven by ICD-10-CM principal diagnosis and ICD-10-PCS procedures — not CPT codes. The DRGs below reflect current MS-DRG v43.0 (FY2026) grouping for GI hemorrhage.

Primary Pathway — MDC 06 (Digestive System) — GI Hemorrhage DRGs

When the principal diagnosis is from the GI hemorrhage code set (K25-K28.x with hemorrhage, K92.0, K92.1, K92.2, K29.01, K31.811, K22.6):

MS-DRG	Description	CC/MCC
377	GI Hemorrhage	w MCC
378	GI Hemorrhage	w CC
379	GI Hemorrhage	w/o CC/MCC

DRG Severity — MCC/CC Capture Opportunities

Conditions that elevate a GI hemorrhage case to the MCC or CC tier include:

• D62 (Acute posthemorrhagic anemia) — CC
• K74.60 (Cirrhosis of liver) — MCC tier depending on severity and HCC implications
• I50.9 (Heart failure) — MCC if acutely decompensated
• Coagulopathy (D68.9 or specific anticoagulant adverse effect codes) — CC/MCC
• Septicemia / Sepsis — MCC
• Respiratory failure — MCC

Accurate secondary diagnosis coding, driven by thorough CDI and physician query, can shift a DRG 379 ($5,500avgpayment)toa\ast \ast DRG377\ast \ast ($15,000+ avg payment) — a profound reimbursement impact.

Alternate Pathway — MDC 06 — Esophagitis / GI Misc (If Non-Hemorrhagic Principal Dx)

MS-DRG	Description	CC/MCC
391	Esophagitis, Gastroenteritis & Misc Digestive Disorders	w MCC
392	Esophagitis, Gastroenteritis & Misc Digestive Disorders	w/o MCC

ICD-10-PCS O.R. Procedure Impact

When 0W3G8ZZ, 0D368ZZ, or another Control code is assigned in the inpatient setting:

• These are non-O.R. procedures in many grouping scenarios
• However, if an open or more invasive procedure is required (e.g., emergent laparotomy for failed endoscopic hemostasis), the PCS O.R. procedure triggers a surgical DRG
• The endoscopic Control codes generally do not override MDC 06 medical DRG assignment, leaving the hemorrhage DRG family (377-379) as the primary assignment

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🔗 Commonly Co-Reported CPT Codes

CPT	Description	Notes
43239	EGD with biopsy	Multiple endoscopy rule applies; report 43255 as primary if wRVU is higher; report 43239 separately at reduced rate
43251	EGD with snare polypectomy	Multiple endoscopy rule; 43255 may be separately reportable if distinct significant post-polypectomy bleed occurred (not minor ooze)
43254	EGD with endoscopic mucosal resection (EMR)	When 43255 is required to control intraoperative bleeding following EMR → APC complexity adjustment (APC 5303, ~$3,939 facility)
43244	EGD with band ligation of esophageal varices	Do NOT combine with 43255 for same variceal episode; use only 43244
43243	EGD with injection of esophageal varices	Same as above — varices are specific to 43243; do not substitute 43255
43270	EGD with ablation of lesion	APC for Barrett’s ablation → 43270; APC to stop bleeding → 43255; if both performed, apply multiple endoscopy rule
99291	Critical care, first 30-74 minutes	When the bedside EGD is performed in the ICU or ER and critical care is provided separately and distinctly from the endoscopy itself; well-documented critical care time is required
99152	Moderate sedation, first 15 min (non-Medicare)	When same physician provides moderate sedation — commercial payers
G0500	Moderate sedation, first 15 min (Medicare)	Medicare-specific moderate sedation add-on code for same physician sedation
99153	Moderate sedation, each additional 15 min	For prolonged moderate sedation; appended to 99152 or G0500
36430	Transfusion of packed red blood cells	If transfusion performed as part of the same admission — separate procedure code; separately reportable
36415	Venipuncture, routine	Labs drawn during admission — separately reportable on separate claim

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⚠️ Coding Traps & Clinical Tips

Trap 1 — Using 43255 for Variceal Hemorrhage

This is the single most consequential coding error in upper GI endoscopy hemostasis coding. Variceal hemorrhage treated with injection sclerotherapy must be coded 43243; variceal band ligation must be 43244. These are not interchangeable with 43255. A procedure note documenting “bleeding esophageal varices — band ligation performed” coded as 43255 is a misrepresentation of the procedure and a compliance violation.

Trap 2 — Stacking 43235 + 43255

43235 (diagnostic EGD) is never reported separately when 43255 is performed in the same session. Surgical endoscopy always includes the diagnostic component. Reporting both 43235 and 43255 is an automatic NCCI bundling violation and will be denied by all payers.

Trap 3 — Minor Post-Polypectomy Ooze Coded as 43255

Automatically adding 43255 to every polypectomy (43251) claim without documentation of a distinct, significant bleeding event is an overcoding error and OIG audit target. The procedure note must document that the bleeding was above and beyond expected minor oozing and required a clinically significant separate intervention.

Trap 4 — Not Applying the Multiple Endoscopy Rule

When 43255 is billed alongside another EGD code (e.g., 43239 or 43251) in the same session, the multiple endoscopy rule applies, not a simple 50% multiple procedure reduction. Coders must identify the base code (43235), the primary (highest-value) procedure, and calculate payment for the secondary procedure correctly. Applying modifier 51 alone without understanding the endoscopy-specific payment methodology leads to incorrect reimbursement expectations.

Tip — "Any Method" Frees You from Device-Specific Code Lookup

Unlike many procedure code families, 43255 does not require the coder to identify or differentiate between specific hemostatic devices. Whether the physician used endoclips, APC, BICAP, heater probe, or all four in sequence — the code is always 43255. Focus your documentation review on: (1) Was active bleeding present? (2) Was a distinct hemostatic intervention performed? (3) Is the bleeding source documented?

Tip — Prophylactic Treatment of High-Risk Stigmata

A nuanced but important issue: some gastroenterologists treat high-risk ulcer stigmata (visible vessel, adherent clot — Forrest IIa, IIb) prophylactically even when active bleeding has stopped. Current ACG guidelines support this as standard of care. From a coding perspective, if the procedure note documents treatment of a visible vessel or adherent clot to prevent re-bleeding, 43255 is appropriate — the physician’s intent was active hemostasis, even if the bleeding was not actively spurting at the time of intervention. However, coders should not assign 43255 based solely on a note documenting “non-bleeding ulcer with no stigmata of recent hemorrhage — no intervention performed.”_{AAPC Codify forum; ACG UGIB Guideline 2021}

Tip — 7th Character for Diagnosis Codes

The peptic ulcer with hemorrhage codes (K25.x, K26.x, K27.x, K28.x) do not use 7th character extensions. They are complete as 5-character codes. Only trauma codes (S, T codes) in ICD-10-CM use 7th character extensions for encounter type.

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📝 Coding Examples

Example 1 — Gastric Ulcer with Active Hemorrhage, Endoclip + Epinephrine Injection

Clinical Scenario: A 67-year-old male on aspirin therapy presents with hematemesis and melena, hemoglobin 7.2 g/dL. Emergency EGD performed in the endoscopy suite reveals a 1.2 cm prepyloric gastric ulcer (Forrest Ia — actively spurting). The gastroenterologist injects 10 mL of 1:10,000 epinephrine submucosally and places three hemostatic endoclips, achieving hemostasis. Biopsy taken for H. pylori. Post-procedure hemostasis confirmed.

CPT (Professional/Physician):

• 43255 — EGD with control of bleeding, any method (primary — epinephrine injection + clips for active bleed)
• 43239-59 — EGD with biopsy (secondary; multiple endoscopy rule applies; modifier 59 per some payer guidance when biopsy is distinct from hemostasis intervention — verify payer-specific policy)

Per the multiple endoscopy rule, 43239 is reimbursed at its fee minus the 43235 base code fee.

ICD-10-CM:

• K25.0 — Acute gastric ulcer with hemorrhage (principal — most specific; replaces symptom codes once source confirmed)
• D62 — Acute posthemorrhagic anemia (secondary — CC; improves DRG severity)
• Z79.02 — Long-term current use of antithrombotics/antiplatelets (aspirin use — secondary)

ICD-10-PCS (Inpatient Facility, if admitted):

• 0D368ZZ — Control Stomach, Via Natural or Artificial Opening Endoscopic

MS-DRG: → MS-DRG 378 (GI Hemorrhage w CC — D62 provides CC tier) or MS-DRG 377 if additional MCC documented

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Example 2 — Post-EMR Bleeding, Same Session Complexity Adjustment

Clinical Scenario: A 55-year-old female undergoes EGD for endoscopic mucosal resection (EMR) of a 15 mm flat gastric polyp. Post-resection, significant arterial bleeding from the resection bed is encountered. The gastroenterologist applies APC coagulation to control the bleeding, achieving hemostasis. Documentation clearly distinguishes the EMR as the primary procedure and the control of bleeding as a distinct, significant separate therapeutic intervention during the same session.

CPT (Professional):

• 43254 — EGD with EMR (primary)
• 43255 — EGD with control of bleeding (secondary — distinct significant bleed, not minor ooze; multiple endoscopy rule applies)

Facility Billing (OPPS/ASC):

• 43254 + 43255 → qualifies for APC complexity adjustment from APC 5302 to APC 5303 (~$3,939 reimbursement to facility)

ICD-10-CM:

• K31.7 — Polyp of stomach and duodenum (principal — indication for EMR)
• K91.840 — Postprocedural hemorrhage of digestive system organ following digestive system procedure (secondary — the post-EMR bleed)

ICD-10-PCS (Inpatient):

• 0DB68ZZ — Excision of Stomach, Via Natural or Artificial Opening Endoscopic (for EMR)
• 0D368ZZ — Control Stomach, Via Natural or Artificial Opening Endoscopic (for hemostasis)

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Example 3 — Mallory-Weiss Tear, APC Hemostasis

Clinical Scenario: A 42-year-old male presents after retching with hematemesis. EGD reveals a 2 cm longitudinal mucosal tear at the gastroesophageal junction (Mallory-Weiss tear) with active oozing. APC coagulation applied across the tear with hemostasis achieved.

CPT (Professional):

• 43255 — EGD with control of bleeding, any method (APC for Mallory-Weiss)

ICD-10-CM:

• K22.6 — Gastro-esophageal laceration-hemorrhage syndrome (Mallory-Weiss tear) (principal)
• D62 — Acute posthemorrhagic anemia (secondary, if documented)

ICD-10-PCS (Inpatient):

• 0D358ZZ — Control Esophagus, Via Natural or Artificial Opening Endoscopic

MS-DRG: → MS-DRG 379 (GI Hemorrhage w/o CC/MCC) without significant comorbidities; MS-DRG 378 with D62 (CC)

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Example 4 — Same-Day Repeat EGD for Re-bleeding

Clinical Scenario: A 74-year-old female with a known duodenal ulcer undergoes emergent EGD at 3:00 AM — clips and epinephrine injection applied with apparent hemostasis. By 11:00 PM the same calendar day she develops hematemesis again. Repeat EGD confirms re-bleeding at the same duodenal ulcer site; additional hemostatic clips placed and Hemospray powder applied.

CPT (Professional — second session same day):

• 43255-76 — Repeat EGD, control of bleeding, same physician, same day

ICD-10-CM:

• K26.4 — Chronic or unspecified duodenal ulcer with hemorrhage (principal — same diagnosis, subsequent session)
• D62 — Acute posthemorrhagic anemia (secondary)

ICD-10-PCS (Inpatient — second procedure):

• 0D398ZZ — Control Duodenum, Via Natural or Artificial Opening Endoscopic

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Example 5 — Inpatient Admission, GAVE (Watermelon Stomach), APC Ablation

Clinical Scenario: A 68-year-old female with cirrhosis and transfusion-dependent anemia is admitted for EGD treatment of gastric antral vascular ectasia (GAVE — “watermelon stomach”). APC treatment applied to multiple antral vascular lesions. This represents a planned therapeutic session for known GAVE, not acute hemorrhage.

CPT (Professional):

• 43270 — EGD with ablation of lesion(s) (APC for GAVE ablation — this is ablation of lesions, NOT control of active bleeding → 43270, not 43255)

GAVE Ablation vs. GAVE Bleeding Control

When APC is used for scheduled ablation of GAVE lesions (planned treatment of known vascular ectasia without active bleeding at the time of procedure), the correct code is 43270 (EGD with ablation). 43255 is appropriate when APC is used to actively stop hemorrhage during the procedure. The clinical context and documentation drive the distinction.

ICD-10-CM:

• K31.811 — Angiodysplasia of stomach and duodenum with bleeding (principal)
• D62 — Acute posthemorrhagic anemia (secondary)
• K74.60 — Unspecified cirrhosis of liver (secondary — HCC 27 relevant; significant for risk adjustment)

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📚 Sources

_{AMA CPT Professional Edition 2025 · CMS Medicare Physician Fee Schedule MPFS RVU File FY2025 (Addendum B) · AGA MPFS RVU Tracking Tables CY2021-CY2025 · ASGE Coding and Reimbursement Guide 2024 · Medtronic 2026 Endoscopy Reimbursement Guide · AGA CPT Advisors Gastroenterology Coding 2014 (43255 variceal parenthetical revision) · ICD-10-CM Official Guidelines for Coding and Reporting FY2026 · ICD-10-PCS Official Guidelines for Coding and Reporting FY2026 (Guideline B4.3) · CMS MS-DRG v43.0 Definitions Manual FY2026 · CMS NCCI Policy Manual Chapter XI (Endoscopy) 2025 · ACG Clinical Guideline: Upper GI and Ulcer Bleeding AJGH 2021 · ESGE Upper GI Bleeding Guideline 2021 · FindACode.com — Billing Endoscopic Procedures: The Multiple Endoscopy Rule · BellMedEx EGD CPT Codes Guide Dec 2025 · ICD10data.com — K25.0, K26.0, K92.0, K92.1, K92.2 FY2026}