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CPT®
43258

CPT® Code 43258
Deleted

Code deleted, see 43270

Official Description

Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 43258 involves an upper gastrointestinal endoscopy, which is a minimally invasive diagnostic and therapeutic procedure. This procedure encompasses the examination of the esophagus, stomach, and, when appropriate, the duodenum and/or jejunum. The primary purpose of this endoscopy is to identify and treat lesions such as tumors or polyps that cannot be removed using standard techniques like hot biopsy forceps, bipolar cautery, or snare techniques. During the procedure, a flexible fiberoptic endoscope is utilized, allowing for direct visualization of the upper gastrointestinal tract. The endoscope is inserted through the mouth and advanced down the esophagus into the stomach and beyond, enabling thorough inspection of the mucosal surfaces. If any abnormal growths are detected, the procedure includes the ablation of these lesions using advanced techniques, such as laser ablation, which effectively destroys the targeted tissue. This comprehensive approach not only aids in diagnosis but also facilitates immediate therapeutic intervention, enhancing patient outcomes.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The upper gastrointestinal endoscopy with ablation described by CPT® Code 43258 is indicated for various conditions where lesions are present in the upper gastrointestinal tract. The following are the explicitly provided indications for this procedure:

  • Presence of Tumors Lesions that are identified as tumors within the esophagus, stomach, or duodenum/jejunum that require intervention.
  • Polyps The presence of polyps that are not amenable to removal by standard techniques and require ablation for treatment.
  • Other Lesions Any other abnormal lesions that cannot be effectively removed using hot biopsy forceps, bipolar cautery, or snare techniques.

2. Procedure

The procedure for CPT® Code 43258 involves several critical steps to ensure effective examination and treatment of the upper gastrointestinal tract. The following procedural steps are outlined:

  • Step 1: Anesthesia Administration The procedure begins with the administration of an anesthetic spray to numb the mouth and throat, facilitating the insertion of the endoscope and minimizing discomfort for the patient.
  • Step 2: Insertion of the Endoscope A hollow mouthpiece is placed in the patient's mouth to keep it open. The flexible fiberoptic endoscope is then carefully inserted and advanced as the patient swallows, allowing for smooth passage through the esophagus.
  • Step 3: Visualization and Inspection Once the endoscope has passed beyond the cricopharyngeal region, it is guided using direct visualization. The esophagus is thoroughly inspected for any abnormalities, which are noted for further evaluation.
  • Step 4: Examination of the Stomach The endoscope is advanced into the stomach, where air is insufflated to expand the stomach for better visibility. The cardia, fundus, greater and lesser curvature, and antrum of the stomach are inspected, and any abnormalities are documented.
  • Step 5: Advancement to the Duodenum/Jejunum The tip of the endoscope is passed through the pylorus into the duodenum and/or jejunum, where the mucosal surfaces are inspected for any lesions or abnormalities, which are also noted.
  • Step 6: Lesion Ablation After the inspection, the endoscope is withdrawn, and any identified tumors, polyps, or lesions are ablated using a laser device. The laser is delivered through the endoscope to the distal margin of the lesion, and ablation is performed by retracting the endoscope while the laser traverses the entire lesion, effectively destroying it.

3. Post-Procedure

Post-procedure care following the upper gastrointestinal endoscopy with ablation includes monitoring the patient for any immediate complications related to the procedure. Patients may experience some throat discomfort or mild pain, which typically resolves quickly. It is essential to provide instructions regarding dietary restrictions, such as avoiding solid foods for a specified period, and to monitor for any signs of complications, such as bleeding or infection. Follow-up appointments may be necessary to assess the effectiveness of the ablation and to conduct further evaluations if needed.
Short Descr OPERATIVE UPPER GI ENDOSCOPY
Medium Descr UPR GI NDSC ABLTJ LES X RMVL FORCEPS/CAUT/SNARE
Long Descr Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 3 - Special rules for multiple endoscopic procedures apply...
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Endoscopic Base Code 43235  Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) none
MUE Not applicable/unspecified.
CCS Clinical Classification 70 - Upper gastrointestinal endoscopy, biopsy
Date
Action
Notes
2014-01-01 Deleted Code deleted, see 43270
Pre-1990 Added Code added.
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