CPT 43226
Global 000 ActiveEsoph endoscopy dilation
CPT 43226 Billing & Documentation Guide
CPT code 43226 (Esoph endoscopy dilation) is classified under Surgery (Digestive) with a global period indicator of 000. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 2.18, a non-facility practice expense RVU of 9.89, and a malpractice RVU of 0.36, a total non-facility RVU of 12.43 and facility RVU of 3.51. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $429.34, though rates vary from $362.76 to $563.61 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 43226, 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 43226 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 43226 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 43226
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 2.18 | 2.18 |
| Practice Expense RVU | 9.89 | 0.97 |
| Malpractice RVU | 0.36 | 0.36 |
| Total RVU | 12.43 | 3.51 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 43226
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 | $472.82 | $120.28 | $442.54 - $563.61 | 29 |
| Florida | $427.66 | $128.73 | $406.69 - $447.1 | 3 |
| Georgia | $402.45 | $118.22 | $381.81 - $423.09 | 2 |
| Illinois | $415.23 | $127.35 | $393.2 - $433.88 | 4 |
| Michigan | $399.93 | $120.16 | $387.99 - $411.86 | 2 |
| North Carolina | $388.7 | $110.73 | $388.7 - $388.7 | 1 |
| New York | $461.14 | $128.76 | $395.09 - $492.57 | 5 |
| Ohio | $386.53 | $114.51 | $386.53 - $386.53 | 1 |
| Pennsylvania | $409.89 | $118.06 | $387.42 - $432.35 | 2 |
| Texas | $409.6 | $116.28 | $384.59 - $433.11 | 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 43226
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 43226 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 43226
What does CPT code 43226 mean? +
CPT code 43226 represents: Esoph endoscopy dilation. It's in the Surgery (Digestive) category with a global period of 000.
What is the Medicare reimbursement for CPT 43226? +
The 2026 Medicare national average non-facility payment for CPT 43226 is $429.34. Rates range from $362.76 to $563.61 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 43226? +
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 43226? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on April 17, 2026.
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