CPT 43420
Global 090 ActiveRepair esophagus opening
CPT 43420 Billing & Documentation Guide
CPT code 43420 (Repair esophagus opening) is classified under Surgery (Digestive) with a global period indicator of 090. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 16.36, a non-facility practice expense RVU of 7.56, and a malpractice RVU of 2.39, a total non-facility RVU of 26.31 and facility RVU of 26.31. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $889.47, though rates vary from $804.46 to $1132.57 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 43420, 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 43420 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
90-day global period (major surgery: 1 day pre-op + procedure + 90 days post-op)
MUE Limit (Medically Unlikely Edits)
Submitting more than 1 units of 43420 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 43420
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 16.36 | 16.36 |
| Practice Expense RVU | 7.56 | 7.56 |
| Malpractice RVU | 2.39 | 2.39 |
| Total RVU | 26.31 | 26.31 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 43420
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 | $908.1 | $908.1 | $875.27 - $1013.46 | 29 |
| Florida | $955.19 | $955.19 | $907.82 - $1011.19 | 3 |
| Georgia | $883.67 | $883.67 | $866.83 - $900.5 | 2 |
| Illinois | $944.89 | $944.89 | $901.75 - $987.24 | 4 |
| Michigan | $895.91 | $895.91 | $867.11 - $924.7 | 2 |
| North Carolina | $833.04 | $833.04 | $833.04 - $833.04 | 1 |
| New York | $962.58 | $962.58 | $842.44 - $1029.89 | 5 |
| Ohio | $857.45 | $857.45 | $857.45 - $857.45 | 1 |
| Pennsylvania | $884.03 | $884.03 | $853.68 - $914.37 | 2 |
| Texas | $872.19 | $872.19 | $850.38 - $911.4 | 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 43420
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 43420 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 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 |
| 0228T | Column 1 (primary), can be billed with modifier | No | Standards of medical/surgical practice |
| 0230T | Column 1 (primary), can be billed with modifier | No | Standards of medical/surgical practice |
| 0596T | Column 1 (primary), can be billed with modifier | Yes | Standards of medical/surgical practice |
| 0597T | Column 1 (primary), can be billed with modifier | Yes | Standards of medical/surgical practice |
| 0708T | Column 1 (primary), can be billed with modifier | Yes | Standards of medical/surgical practice |
| 0709T | Column 1 (primary), can be billed with modifier | Yes | Standards of medical/surgical practice |
| 0903T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0904T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 43420
What does CPT code 43420 mean? +
CPT code 43420 represents: Repair esophagus opening. It's in the Surgery (Digestive) category with a global period of 090.
What is the Medicare reimbursement for CPT 43420? +
The 2026 Medicare national average non-facility payment for CPT 43420 is $889.47. Rates range from $804.46 to $1132.57 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 43420? +
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 43420? +
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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