CPT code 43242 – EUS-guided fine needle aspiration via upper endoscopy

Key takeaways

CPT code 43242 covers an upper endoscopy with EUS-guided fine needle aspiration, and the complete EUS exam is included rather than billed separately.

No needle pass means no 43242. Use 43259 for a complete EUS exam or 43237 for a limited one.

EUS-guided FNA with only a limited exam is 43238, so the procedure note must state how far the exam went.

For 2026, 43242 carries 6.88 total RVUs and pays about $229.80 nationally, the same in facility and non-facility settings before GPCI.

Moderate sedation by the endoscopist is reported separately with 99152 and 99153, while a separate anesthesia provider usually bills 00731.

CPT code 43242 covers a full upper EUS exam plus needle sampling

CPT code 43242 is the code for an esophagogastroduodenoscopy (EGD) with ultrasound-guided fine needle aspiration (FNA) or biopsy through the scope. Per the official descriptor, it includes the endoscopic ultrasound (EUS) exam of the esophagus, stomach, and duodenum. After gastric surgery, the jejunum examined distal to the anastomosis stands in for the duodenum.

The sample can come from inside the GI wall (intramural) or from a structure just beyond it (transmural). The AMA’s CPT code set treats the EUS exam as part of 43242. Billing a separate EUS code for the same session trips National Correct Coding Initiative (NCCI) edits. CPT also bars reporting 76942 or 76975 with it.

Two scenarios fall outside 43242. Diagnostic EUS without FNA goes to 43237 (limited EUS) or 43259 (complete upper GI EUS). EUS-guided FNA of the lower GI tract belongs to a separate code family, such as 45342 for sigmoidoscopy or 45392 for colonoscopy. And an esophagus-only FNA done through an esophagoscope is 43232.

How the EUS-guided FNA procedure runs, step by step

Each step below leaves something in the procedure note that a payer can check during a medical necessity review.

1. Patient preparation: the patient receives moderate sedation or monitored anesthesia care (MAC). Anticoagulants are reviewed, and antiplatelet agents may be held per the endoscopist’s protocol.
2. Scope insertion: a linear-array echoendoscope (or a radial scope followed by a linear one) goes in through the mouth. It is advanced through the esophagus, stomach, and duodenum.
3. EUS examination: the endoscopist images the target lesion with real-time ultrasound. Common targets are a pancreatic mass, a submucosal tumor, a mediastinal lymph node, or a perigastric structure. All three segments are surveyed, which is what the descriptor requires.
4. FNA needle pass: a 19-, 22-, or 25-gauge needle passes through the instrument channel under EUS guidance. Ultrasound confirms the needle tip sits in the lesion. Several passes are usually made until the sample is adequate, and many centers check this in the room with rapid on-site evaluation (ROSE).
5. Specimen handling: the aspirate goes onto slides or into preservative and is sent to pathology. The procedure report records the number of passes, the needle gauge, and specimen adequacy.

If the operative note skips any of these steps, the claim is exposed on medical necessity review.

What the procedure note must say to support 43242

A clean claim for CPT 43242 starts with a procedure note that answers every question an auditor asks. When an element is missing, the claim usually comes back denied. The report should state each of the following:

• Indication and medical necessity: the clinical reason for EUS-FNA. Typical examples are a pancreatic mass on CT, a submucosal lesion on a prior EGD, or mediastinal adenopathy. Tie it directly to the ICD-10 code on the claim.
• Scope type: a flexible, transoral echoendoscope. The descriptor uses that exact language, and leaving it out invites a technical denial.
• Extent of the EUS exam: state that the esophagus, stomach, and duodenum (or jejunum after surgery) were examined. This is the line that separates 43242 from 43238.
• Lesion characteristics: size, echogenicity, location within the GI wall layers, and relationship to nearby structures.
• FNA details: needle type and gauge, number of passes, whether ROSE was used, and the adequacy assessment.
• Pathology request: confirmation that the specimen went for cytology or histology, which shows the FNA was diagnostic.
• Anesthesia: whether moderate sedation, MAC, or general anesthesia was used, since that drives separate billing (see below).

The superbill for the encounter must carry an ICD-10 code that supports the indication in the procedure note. A mismatch between the two documents is a leading audit trigger.

ICD-10 codes that establish medical necessity for 43242

Payers judge medical necessity from the ICD-10-CM code submitted with CPT 43242. An unsupported or mismatched diagnosis is one of the most frequent denial reasons for this procedure.

The table lists the diagnoses most often linked to it. Check each pairing against the applicable local coverage determination (LCD) or payer policy before you submit.

Always assign the most specific code available. K31.9 works while a more precise diagnosis is still pending. Payers may challenge it, though, if it keeps appearing across one patient’s claims. The AAPC Codify CPT lookup includes a crosswalk that helps coders check supported pairings before submission.

CPT 43242 pays the same in facility and non-facility settings for 2026

Medicare sets payment for CPT 43242 each year through the Medicare Physician Fee Schedule (MPFS). For 2026, the national RVUs and payment are identical in facility and non-facility settings. Your locality amount still shifts with the Geographic Practice Cost Index (GPCI) and the site-of-service rules.

These are national figures, so check your locality’s amount in the CMS Physician Fee Schedule Look-Up Tool before you quote a fee. Commercial rates vary widely and follow each payer contract. The FastRVU 2026 lookup is a quick cross-check for the work RVU and total RVU.

Modifiers for CPT 43242 apply only in narrow cases

Modifier errors are another frequent denial trigger for 43242. Each modifier below fits one specific situation. Appending the wrong one, or leaving off a required one, changes how the payer adjudicates the claim.

43242 vs 43237, 43238, 43239 and 43259: Two questions pick the code

Five upper GI codes get mixed up in EUS billing. Two questions settle almost every case. Was a needle pass made under EUS guidance? And how far did the ultrasound exam go?

Laid out as a grid, the needle pass and the exam’s extent point to one code each.

A common error looks like this. The endoscopist performs EUS imaging only, with no needle pass, and the claim still goes out as 43242. Without FNA, the code is 43237 if the EUS exam was limited. It is 43259 if the full esophagus, stomach, and duodenum exam was done.

Forceps biopsy is the other trap. Code 43239 bundles into 43242 under NCCI edits. A forceps biopsy of a separate lesion in the same session may still be reported with modifier 59 when the note supports it.

Duct brushing and washing are a third route to tissue. Both are built into 43260, the diagnostic ERCP code, so neither is reported separately when the duct is sampled that way.

Prior authorization for 43242 depends on the plan, not the code

Prior authorization (PA) rules for 43242 vary by payer, plan, and region. Traditional Medicare does not require PA for 43242. Medicare Advantage (MA) plans increasingly do, and each plan sets its own criteria.

Skip PA on a plan that requires it and you can expect a non-covered service denial. A participating provider usually cannot bill the patient for that service without a signed Advance Beneficiary Notice (ABN) or the plan’s equivalent notice.

For commercial payers, the PA request for 43242 typically needs:

• The referring provider’s clinical notes documenting the indication (mass, adenopathy, or lesion on prior imaging)
• Imaging reports (CT, MRI, or prior endoscopy) that identified the lesion
• The proposed CPT code (43242) and the linked ICD-10 diagnosis code
• The performing endoscopist’s credentials and facility information
• The proposed procedure date and site of service

Medicaid programs vary by state. Some require PA for every EUS procedure, while others cover 43242 without it when medical necessity criteria are met. Verify with the specific plan before scheduling.

Why 43242 claims get denied, and how to fix each one

Most 43242 denials are preventable. Good denial management workflows start with logging every CARC denial code you receive against this code. Patterns then become visible. The table maps the most common denial reasons to their fixes.

The zero-day global period for 43242 affects only the procedure day

CPT 43242 carries a zero-day (000) global surgical period under the Medicare Physician Fee Schedule, like other upper endoscopy codes. Check the current-year MPFS, because Medicare Advantage and commercial contracts can assign different periods.

A 000 global bundles no postoperative visits into the procedure payment. Here is how evaluation and management (E/M) visits work around it:

• Same-day E/M (modifier 25): a separately identifiable E/M on the procedure date takes modifier 25 on the E/M code. A new problem addressed at the same visit is the typical case. Routine pre-procedure assessment is part of 43242 and is not billed separately.
• Modifier 24 does not apply: modifier 24 marks an unrelated E/M during a postoperative period. A 000 global has no postoperative days, so 43242 never needs it.
• Pathology results visit: a later visit to discuss biopsy results is billed as a standard office E/M, with no modifier.

Anesthesia and sedation for 43242 are billed on their own codes

When a separate anesthesiologist or certified registered nurse anesthetist (CRNA) provides anesthesia for EUS-FNA, they bill it on their own claim. The endoscopist bills 43242.

Anesthesia providers usually report 00731 for EUS-FNA. Code 00813 applies only when a lower GI endoscopy is also done in the same session. Confirm the base code with the anesthesia group before submitting.

• Who bills it: the anesthesia provider bills the anesthesia code on their own claim, and the endoscopist bills 43242. These are two separate claims.
• MAC vs general anesthesia: monitored anesthesia care uses the same base code as general anesthesia. The difference shows in the documentation, so the anesthesia note should name the type given.

Moderate sedation works differently. The 2017 CPT changes removed it from endoscopy codes, so it is no longer bundled into 43242. When the endoscopist provides it, report 99152 for the first 15 minutes in patients age 5 or older. Add 99153 for each additional 15 minutes.

Before you submit a 43242 claim: A quick checklist

Run through these points on every EUS-FNA claim before it leaves the practice:

• The note states that FNA was performed, with the needle type, gauge, and number of passes.
• The note names the anatomy examined: esophagus, stomach, and duodenum, or the jejunum after gastric surgery.
• The code matches the note. It is 43242, not 43238, 43259, or 43237.
• No separate EUS code, 76942, or 76975 sits on the same claim.
• The ICD-10-CM code matches the indication and the applicable LCD.
• A PA number is on file for any MA or commercial plan that requires one.
• Moderate sedation by the endoscopist is coded with 99152 and 99153, and any anesthesia provider has the details for their own claim.
• Any separate same-day E/M carries modifier 25 and its own documentation.

How Pabau handles claim submission for 43242 procedures

Many GI practices still key each 43242 claim into a clearinghouse portal by hand. The remittance then lands somewhere else, and someone matches payments to claims in a spreadsheet.

Pabau, the practice management platform we build, keeps that loop in one system. For cleaner claims management, it pre-fills the CMS-1500 from the patient record. It also checks required fields, such as member ID and authorization number, before the claim can be sent.

In the US, claims go out electronically through the Claim.MD integration. Eligibility checks, claim status, and electronic remittance advice (ERA) come back into Pabau. Code choice and modifiers stay with your coders, so the checklist above still applies.

Send 43242 claims and track remittances together

Pabau pre-fills each claim from the patient record, checks required fields, and submits it through Claim.MD. Remittances and claim status come back to the same system, so denied EUS-FNA claims surface quickly.

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Conclusion

Get the code choice right before the claim exists. For 43242, the procedure note has to state the needle pass and the full extent of the EUS exam, in words a payer can find.

Build both into a note template the endoscopist completes before leaving the room. Your coder can then choose between 43242, 43238, 43259, and 43237 from the note, not from memory. Fewer claims come back for correction, and the 2026 payment has a better chance of landing on the first pass.

The trade-off is a slightly longer note, and that minute costs far less than a resubmission. Book a demo to see how Pabau sends procedure claims and brings the remittances back into one system.

Continue your research

Need to understand how claim errors get tracked and resolved? Electronic remittance advice explains how ERA files carry CARC and RARC denial reason codes back to your billing team after each claim adjudication.

Submitting claims through a clearinghouse for the first time? Medical claims clearinghouse covers how clearinghouses validate, translate, and route 837P files to payers, and what to look for when choosing one.

Want to reduce the time between procedure and payment? Revenue cycle management outlines the end-to-end workflow from eligibility verification through final payment posting for procedure-based specialties.

Chasing approvals before an EUS-FNA? Prior authorization process walks through each step from request to approval, and what payers expect at each stage.

Frequently asked questions