Abstract from Documentation: What is an upper endoscopy?

Procedure: Upper endoscopy

Indication: The patient is a 45-year-old female who presents with five years of reflux symptoms. She has had some intermittent epigastric abdominal discomfort as well.

Description of Procedure: After obtaining informed consent and establishment of an intravenous line, the patient was positioned in the left lateral decubitus position. We used 10 mg of midazolam, 50 mcg of fentanyl, and supplemental oxygen at 2 liters per nasal cannula. She was monitored with pulse oximetry, continuous ECG tracing, and periodic blood pressure checks. A flexible video Olympus upper endoscope was passed through the oropharynx into the esophagus. The esophagus was unremarkable including the squamocolumnar junction at 36 cm from the incisors. Proximal gastric view including retroflexion showed minimal gastric valve laxity but was otherwise unremarkable. She had a series of three polyps in the general range of 5 to 7 mm in the mid gastric lumen, in line with the greater curvature of the stomach. One was more inflamed than the other two. All three were removed with standard snare polypectomy technique. The rest of the stomach was intact as was the pylorus, duodenal bulb, and second portion of the duodenum. All areas were resurveyed two additional times and we simply identified no additional findings. She tolerated the procedure well and without apparent complication.

Assessment: Gastric polyps as mentioned above. Otherwise unremarkable upper endoscopy.

An upper gastrointestinal endoscopy is a procedure that uses a lighted instrument (scope) to visualize the esophagus, stomach, and duodenum. The CPT code description also includes the possibility of visualizing the jejunum; however, this is not typical.

Did the physician just visualize the structures or perform another procedure during the endoscopy?
Answer: There were 3 polyps removed from the stomach, using a snare technique.


CPT Index Term (there may be several entries in the index leading to the correct range)
43247, 43250–43251 Endoscopy, Gastrointestinal, Upper, Removal

CPT Code Assignment:
43251 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyps(s), or other lesion(s), by snare technique
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