Upper Endoscopy (EGD) With Biopsy price: Medicare anchor and facility lever
Anchor for Upper Endoscopy (EGD) With Biopsy - CPT 43239
$128.48
Nonfacility PFS $413.41; facility professional PFS $128.48.
Hospital OPPS facility anchor, this code billed alone: $926.63 (APC 5301, Level 1 Upper GI Procedures; national unadjusted, before wage-index adjustment).
EGD with biopsy, CPT 43239, is the upper endoscopy code used when tissue is sampled. Unlike colonoscopy, the hospital facility APC does not move when the biopsy is added; the professional anchor and the pathology bill do. That makes the professional and lab lines the place to check on a 43239 quote.
CPT code
43239
Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
CPT 43239 is EGD with biopsy. Diagnostic EGD without biopsy is 43235. Confirm the expected code before comparing quotes, because a biopsy changes both the procedure code and the pathology bill.
The codes this visit can be billed under
| CPT | PFS office or global | PFS facility (professional) | Global period | Hospital single-service APC | Minimum Medicare copay at hospital |
|---|---|---|---|---|---|
| 43239 (this page) | $413.41 | $128.48 | 0 days | $926.63 (APC 5301) | $185.33 |
| 43235 | $319.52 | $114.85 | 0 days | $926.63 (APC 5301) | $185.33 |
| 88305 | $69.02 | $69.02 | not a surgical global | $53.24 (APC 5671) | $10.65 |
In CY2026, 43239 and diagnostic 43235 share hospital APC 5301 at $926.63, with a minimum unadjusted copayment of $185.33. The facility professional anchor rises from $114.85 to $128.48 for Michigan Locality 01.
One code covers single or multiple biopsies, so the procedure line does not change with the number of samples. The pathology bill can change, because it depends on how the lab handles what was sent; ask the lab how it bills when more than one specimen container is submitted. The common pathology code is 88305.
For a Medicare patient, the hospital line for 43239 carries a minimum unadjusted copayment of $185.33, the same as for diagnostic 43235 because the two codes share APC 5301. The endoscopist's coinsurance is figured on the $128.48 facility professional anchor, and the pathologist's charge, commonly 88305 with a $69.02 global anchor, has its own coinsurance.
In an office endoscopy suite, the CY2026 nonfacility anchor for 43239 is $413.41, which includes the practice expense that a hospital or surgery center would otherwise bill as a facility fee. That is why an office quote for EGD with biopsy can look higher on the professional line yet lower in total.
For the pathology layer, the CY2026 Michigan Locality 01 professional component of CPT 88305 is $34.94 out of its $69.02 global anchor, and CMS Addendum B lists 43239 with status indicator T.
Inside and outside the 43239 anchor
Covered by the anchor
- Endoscopist professional fee for EGD with biopsy (PFS anchor below)
- Use of the endoscopy suite and standard recovery monitoring in the facility payment
Billed outside it
- Anesthesia or sedation billed separately
- Pathology for the biopsy specimen (for example 88305)
- The pre-procedure visit and follow-up visit when billed separately
Why prices vary for CPT 43239
Like diagnostic EGD, pricing splits into professional, facility, anesthesia, and pathology layers. The professional anchor is lower in a facility setting than in an office because the facility payment carries the overhead. Hospital OPPS facility payment is higher than the ASC facility payment for the same upper GI family.
Ask for the setting (hospital vs ASC vs office), the anesthesia plan, and whether a biopsy is expected. Price each layer separately, then add them.
Questions specific to EGD with biopsy
- Is the written price for 43239, or only for diagnostic 43235?
- If several samples are taken, how will the lab bill them?
- Is the facility a hospital department or a surgery center?
- Who provides sedation, and is that billed separately?
- Is the quote from a hospital or a surgery center, and which facility fee does it include?
Upper Endoscopy (EGD) With Biopsy: billing questions
Does the number of biopsies change the EGD code?
No. CPT 43239 covers single or multiple biopsies. The pathology bill may change with the number of specimens sent.
Why is my hospital facility charge the same with or without a biopsy?
In CY2026 both 43235 and 43239 map to APC 5301, so the hospital's Medicare facility anchor does not change. The professional anchor and pathology charge do.
What is 88305 on my bill?
CPT 88305 is a common pathology code for examining a tissue specimen. It is billed by the pathologist or lab, not the endoscopist, and its CY2026 anchor is in the code table on this page.
Is a follow-up visit after EGD with biopsy included?
Not under the Medicare fee schedule: 43239 has a 0-day global period in the CY2026 file, so a later visit to discuss results is billed as its own service. Ask the practice how it handles follow-up.