CPT 43204
Global 000 ActiveEsoph scope w/sclerosis inj
CPT 43204 Billing & Documentation Guide
CPT code 43204 (Esoph scope w/sclerosis inj) is classified under Surgery (Digestive) with a global period indicator of 000. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 2.27, a non-facility practice expense RVU of 1.09, and a malpractice RVU of 0.25, a total non-facility RVU of 3.61 and facility RVU of 3.61. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $122.51, though rates vary from $111.39 to $157.1 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 43204, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 43204 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
Endoscopic or minor procedure with related preoperative and postoperative work performed on the same day
MUE Limit (Medically Unlikely Edits)
Submitting more than 1 units of 43204 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 43204
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 2.27 | 2.27 |
| Practice Expense RVU | 1.09 | 1.09 |
| Malpractice RVU | 0.25 | 0.25 |
| Total RVU | 3.61 | 3.61 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 43204
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $126.15 | $126.15 | $121.49 - $141.13 | 29 |
| Florida | $128.61 | $128.61 | $123.18 - $134.84 | 3 |
| Georgia | $120.66 | $120.66 | $118.25 - $123.07 | 2 |
| Illinois | $127.22 | $127.22 | $122.11 - $132.1 | 4 |
| Michigan | $121.76 | $121.76 | $118.49 - $125.03 | 2 |
| North Carolina | $115.12 | $115.12 | $115.12 - $115.12 | 1 |
| New York | $131.38 | $131.38 | $116.28 - $139.47 | 5 |
| Ohio | $117.48 | $117.48 | $117.48 - $117.48 | 1 |
| Pennsylvania | $121.09 | $121.09 | $117.13 - $125.05 | 2 |
| Texas | $119.84 | $119.84 | $116.71 - $124.07 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 43204
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 43204 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 00520 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00731 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00732 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00740 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00810 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00811 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00812 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 00813 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 0213T | Column 1 (primary), can be billed with modifier | No | Misuse of Column Two code with Column One code |
| 0216T | Column 1 (primary), can be billed with modifier | No | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 43204
What does CPT code 43204 mean? +
CPT code 43204 represents: Esoph scope w/sclerosis inj. It's in the Surgery (Digestive) category with a global period of 000.
What is the Medicare reimbursement for CPT 43204? +
The 2026 Medicare national average non-facility payment for CPT 43204 is $122.51. Rates range from $111.39 to $157.1 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 43204? +
Surgery codes commonly use modifier 22 (increased procedural services), 50 (bilateral), 51 (multiple procedures), 52 (reduced services), 58/78/79 (staged, unplanned return, unrelated within global), 62 (co-surgeons), 80/82 (assistant surgeon), and 59 or the X{EPSU} subset for distinct procedural service.
What bundling edits apply to CPT 43204? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
Get the full PayerReady toolkit
Free access to CPT/ICD-10 lookup, denial appeals, fee comparator, and claim auditing with credentialing enrollment.
Start free →Run this code through our claim audit tool
Check NCCI bundling, MUE limits, and modifier logic before submission.
Try the auditor →Did this page help?
Quick signal so we know what to improve.
If you want a code reference page that doesn't exist yet, email coding@payerready.com.
Tell us what's missing or wrong: coding@payerready.com. We respond within 5 business days.
Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
Powered by 11K CPT · 98K ICD-10 · 860K MPFS rates · 4.5M NCCI edits · 9.5M NPIs. Our data methodology · About our coding team