Does 43226 require prior authorization?

No, 43226 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 43226?

Medicare facility rate: $117.24. Non-facility rate: $415.17. Work RVU: 2.18.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

2.18

Facility

$117.24

Non-Facility

$415.17

This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information, including complete patient name and dates of service.

Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
EGD is indicated for management of achalasia with endoscopic techniques (e.g., botulinum toxin injection, balloon dilation).
Diagnostic EGD is indicated for persistent upper abdominal distress despite an appropriate trial of therapy.
Diagnostic EGD is indicated for upper abdominal distress with signs suggesting serious organic disease such as anorexia and weight loss.
EGD is indicated for dysphagia or odynophagia to evaluate esophageal pathology.
EGD is indicated for persistent or recurrent gastroesophageal reflux disease (GERD) symptoms despite appropriate medical therapy.

A57414 — Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

J12

L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

J12

AETNA-CPB-0625 — Dysphagia Therapy

A56389 — Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization

L34434 — Upper Gastrointestinal Endoscopy and Visualization

Ask Verity about documentation requirements, denial risks, or coverage in your state.