CPT 43250
Global 000 ActiveEgd cautery tumor polyp
CPT 43250 Billing & Documentation Guide
CPT code 43250 (Egd cautery tumor polyp) is classified under Surgery (Digestive) with a global period indicator of 000. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 2.9, a non-facility practice expense RVU of 11.61, and a malpractice RVU of 0.42, a total non-facility RVU of 14.93 and facility RVU of 4.57. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $515.56, though rates vary from $437.19 to $674.22 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 43250, 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 43250 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 43250 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 43250
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 2.9 | 2.9 |
| Practice Expense RVU | 11.61 | 1.25 |
| Malpractice RVU | 0.42 | 0.42 |
| Total RVU | 14.93 | 4.57 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 43250
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 | $566.8 | $157.35 | $531.04 - $674.22 | 29 |
| Florida | $513.25 | $166.06 | $488.67 - $536.02 | 3 |
| Georgia | $483.74 | $153.63 | $459.49 - $507.99 | 2 |
| Illinois | $498.71 | $164.36 | $472.84 - $520.65 | 4 |
| Michigan | $480.74 | $155.81 | $466.75 - $494.73 | 2 |
| North Carolina | $467.63 | $144.78 | $467.63 - $467.63 | 1 |
| New York | $553.14 | $167.1 | $475.12 - $590.19 | 5 |
| Ohio | $465.05 | $149.12 | $465.05 - $465.05 | 1 |
| Pennsylvania | $492.57 | $153.63 | $466.11 - $519.03 | 2 |
| Texas | $492.2 | $151.53 | $462.78 - $519.76 | 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 43250
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 43250 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 43250
What does CPT code 43250 mean? +
CPT code 43250 represents: Egd cautery tumor polyp. It's in the Surgery (Digestive) category with a global period of 000.
What is the Medicare reimbursement for CPT 43250? +
The 2026 Medicare national average non-facility payment for CPT 43250 is $515.56. Rates range from $437.19 to $674.22 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 43250? +
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 43250? +
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 May 31, 2026.
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