43255

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

CPT code 43255 represents a flexible transoral esophagogastroduodenoscopy (EGD) specifically performed to achieve hemostasis and control bleeding within the upper gastrointestinal tract using any method. The upper gastrointestinal tract includes the esophagus, stomach, and either the duodenal bulb or the second portion of the duodenum. Upper gastrointestinal bleeding is a common and potentially life-threatening emergency that requires prompt endoscopic evaluation and intervention. During this procedure, the physician utilizes a flexible video endoscope, passing it through the patient's mouth and oropharynx down into the esophagus and further into the gastric and duodenal cavities. Upon identifying the source of hemorrhage—which may manifest as an actively bleeding peptic ulcer, a Mallory-Weiss tear at the gastroesophageal junction, bleeding angiodysplasia, a Dieulafoy lesion, or erosive hemorrhagic gastritis—the physician intervenes using one or a combination of hemostatic techniques. These techniques can include thermal coagulation (such as bipolar electrocoagulation, heater probe, or argon plasma coagulation), mechanical therapy (such as the application of endoscopic clips or band ligation, though variceal ligation has a specific code), or injection therapy (such as the submucosal injection of epinephrine or sclerosants to induce vasoconstriction and local tamponade). The chosen method depends on the nature, location, and severity of the bleeding lesion. Endoscopic control of bleeding is critical for stabilizing the patient, reducing the need for blood transfusions, avoiding more invasive surgical interventions, and decreasing mortality. It is important to note that the control of bleeding must be the primary intent or a significant therapeutic addition for a naturally occurring bleed. If a physician causes bleeding during another endoscopic intervention, such as a mucosal biopsy or snare polypectomy, the control of that iatrogenic bleeding is generally considered an integral part of the primary procedure and is not separately reportable with 43255 unless it occurs at a separate anatomical site or during a distinctly separate patient encounter. Post-procedural care typically involves monitoring the patient for re-bleeding, managing their hemodynamic status, and initiating appropriate pharmacological therapies like high-dose proton pump inhibitors.

Clinical Indications

  • Acute upper gastrointestinal hemorrhage
  • Bleeding peptic ulcer disease (gastric or duodenal)
  • Mallory-Weiss tear with active bleeding
  • Dieulafoy lesion in the stomach or duodenum
  • Bleeding gastric or esophageal angiodysplasia (arteriovenous malformations)
  • Hemorrhagic gastritis or esophagitis

Procedure Steps

  1. The patient is positioned in the left lateral decubitus position and administered appropriate sedation or general anesthesia.
  2. A bite block is placed in the patient's mouth to protect the endoscope and the patient's teeth.
  3. The flexible endoscope is introduced through the mouth and advanced through the oropharynx into the esophagus.
  4. The scope is systematically advanced through the esophagus, lower esophageal sphincter, stomach, and into the duodenum.
  5. Air or carbon dioxide is insufflated to distend the lumen and allow for clear visualization of the mucosal surfaces.
  6. The endoscopist identifies the source of the bleeding and flushes the area with water to clear away overlying blood clots.
  7. A therapeutic instrument is passed through the working channel of the endoscope to apply hemostasis (e.g., deploying hemoclips, injecting epinephrine, or applying argon plasma coagulation).
  8. The site is observed for several minutes to confirm complete cessation of bleeding.
  9. The endoscope is safely withdrawn, and the patient is transferred to the recovery area for hemodynamic monitoring.

Coding Guidelines

  • Report 43255 when the primary purpose or a distinct therapeutic service of the EGD is to control bleeding using any method (thermal, injection, or mechanical).
  • Do not report 43255 in conjunction with 43235 (diagnostic EGD) as diagnostic endoscopy is included in the therapeutic procedure.
  • If bleeding is a direct result of an endoscopic intervention (e.g., biopsy or polypectomy) at the same session, control of bleeding is not separately reported. It is considered an inherent part of the procedure.
  • When reporting 43255 along with other upper GI endoscopic codes (e.g., 43239 for biopsy) for procedures performed on separate, distinct lesions, append modifier 59 or the appropriate X-modifier (e.g., XS) to indicate a distinct procedural service.
  • For endoscopic control of bleeding specific to esophageal or gastric varices using band ligation, consider CPT code 43244 instead.