National (GPCI 1.000)
$367.66–$569.97 across payment localities
Last change · 17.3% increase · Q1 2026National (GPCI 1.000)
$114.03–$160.83 across payment localities
Last change · 6.8% decrease · Q1 2026Participating physician · Before sequestration
Compare all payment localitiesFind the locality-adjusted allowed amount
CMS evidence · Q4 2026 release
( Work2.33 × 1.000 + Practice exp.9.94 × 1.000 + Malpractice0.27 × 1.000 ) × Conv. factor$33.4009 = $418.85
F Work RVU
2.33
G Non‑facility PE RVU
9.94
K MP RVU
0.27
Z Conversion factor
33.4009
( Work2.33 × 1.000 + Practice exp.1.10 × 1.000 + Malpractice0.27 × 1.000 ) × Conv. factor$33.4009 = $123.58
F Work RVU
2.33
I Facility PE RVU
1.10
K MP RVU
0.27
Z Conversion factor
33.4009
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Physician relative value file (PPRRVU) · PPRRVU2026_Oct_nonQPP.csv row 5,167 in rvu26d-updated-08-26-2026.zip Download from CMS
Loading rows 5,165–5,169 of PPRRVU2026_Oct_nonQPP.csv…
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Physician relative value file (PPRRVU) · PPRRVU2026_Oct_nonQPP.csv row 5,167 in rvu26d-updated-08-26-2026.zip Download from CMS
Loading rows 5,165–5,169 of PPRRVU2026_Oct_nonQPP.csv…
Nationally priced under PFS, using the RVU formula.
CMS RVU26DOctober 1 – December 31, 2026revision 2
The national PFS baseline is $418.85 for CPT 43239 in the Office (non-facility) setting and $123.58 in a facility under the Q4 2026 Physician Fee Schedule, effective October 2026. These are the national allowed amounts before locality (GPCI) adjustment; sequestration is excluded.
Why are the facility and non-facility amounts different?
Only the practice-expense RVU changes with the setting. For 43239 it's 9.94 RVUs in the Office (non-facility) setting versus 1.10 in a facility—the whole $295.27 gap between $418.85 and $123.58. In the Office (non-facility) setting the practice bears the overhead, so the allowed amount is higher; in a hospital or ASC the facility bills its own fee, so the professional amount is lower. See facility vs non-facility.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov).
About this code
Also known as Upper endoscopy
What could change this amount? Copy link
Here are the inputs and payment rules that apply to this code. Each link takes you to the detail below.
Service location and setting · Participation and payment shares
Other payment indicators (5)
Why would a Medicare claim for 43239 be denied or paid less?
These come from CMS indicators on this page, not general billing advice.
- 118 codes form NCCI pairs with 43239 carrying modifier indicator 0—no NCCI-associated modifier bypasses the edit, so billed together on the same date of service, a line of the pair denies. See billing together
- 220 codes pair with 43239 under modifier indicator 1—separately payable only when an NCCI-associated modifier (59, or a more specific XE, XS, XP, or XU) is clinically appropriate and the documentation supports a distinct service; without one, a line of the pair denies. See billing together
- More than 1 unit per patient per date of service exceeds 43239's Medically Unlikely Edit (MUE) limit. See billing together
- Bilateral surgery: no bilateral adjustment. See billing policy
- Assistant at surgery: never separately payable. See billing policy
- Co-surgeons: not permitted. See billing policy
- Team surgery: not permitted. See billing policy
- Multiple procedures: special endoscopic rules apply. See billing policy
Payer-specific coverage and documentation rules live outside these files, so a claim that clears every check here can still be denied on other grounds.
What do commercial payers pay for 43239? Copy link
Negotiated rates for 43239 vs Medicare Copy link
Commercial payers' negotiated rates for 43239 have medians of 128% to 193% of Medicare, depending on specialty.
Insurers must publish the rates they negotiate with in-network clinicians (the Transparency in Coverage rule). We reduce each file to medians by county and specialty and set them against Medicare's amount for the same place.
BCBSTX Blue Choice PPO · Harris County, TX
Rate file of October 2026
Medicare (100%): $127.34, the PFS Q4 2026 facility amount in this county's payment locality.
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General Surgery
760 providers · 257 groups
193% 150–348%
Median $245.34 · middle half $190.98–$443.21
BCBSIL PPO · Cook County, IL
Rate file of October 2026
Medicare (100%): $135.99, the PFS Q4 2026 facility amount in this county's payment locality.
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General Surgery
625 providers · 208 groups
128% 128–182%
Median $174.67 · middle half $174.67–$247.20 · 51% of providers at exactly $174.67
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Gastroenterology
350 providers · 130 groups
133% 128–177%
Median $180.78 · middle half $174.67–$241.38
How does your contract compare? Enter your % of Medicare
Payers publish this data, and each dataset carries its month. A negotiated rate describes the contract, not the payment, and networks and plan designs vary. We publish a benchmark only when at least 10 providers from at least 5 separately contracting groups (tax IDs) stand behind it, and no single group accounts for more than 25% of it. Browse all payer benchmarks →
Contracted rate: % of Medicare Copy link
Commercial contracts are often written as a percentage of Medicare ("115% of Medicare"). Enter yours to see what it means for 43239. A contract benchmarked to the fee schedule applies it to your locality's allowed amount, not the $418.85 national baseline; the calculator finds that amount from your service ZIP.
How location and RVUs set the amount Copy link
Rates by locality Copy link
The national baseline uses GPCI 1.000. These locality-adjusted allowed amounts use each payment locality's own GPCIs. Select a state to see its localities.
43239 Office (non-facility) rate by metro area
Highest amount first. Each figure is that payment locality's own GPCI-adjusted allowed amount.
Show 55 more metros Show fewer metros
43239 facility rate by metro area
Highest amount first. Each figure is that payment locality's own GPCI-adjusted allowed amount.
Show 55 more metros Show fewer metros
Q4 2026 amounts, computed with each locality's own GPCIs, before the ~2% sequestration cut. A state with more than one payment locality shows a range—its tile is colored by the mean across those localities, which is a shading choice, not an amount anyone is paid.
How this amount is computed Copy link
CPT 43239 has a work RVU of 2.33, a non-facility practice expense RVU of 9.94, a facility practice expense RVU of 1.10 and a malpractice RVU of 0.27—for total non-facility RVUs of 12.54 and total facility RVUs of 3.70 in the Q4 2026 release.
The formula is: (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor. National amounts use GPCI = 1.000. To price an RVU figure of your own, use the RVU-to-dollars converter.
| Component | RVU |
|---|---|
| Work RVU | 2.33 |
| Practice expense RVU (non-facility) | 9.94 |
| Practice expense RVU (facility) | 1.10 |
| Malpractice RVU | 0.27 |
Every rate combines three parts: work (the clinician’s time, skill and effort), practice expense (office overhead—higher when the service is done in a doctor’s own office), and malpractice (the share of liability-insurance cost). A blank means CMS publishes no national number for that part. Read it as unknown, never as zero.
CMS RVU26DOctober 1 – December 31, 2026revision 2 See file rows
Allowed amount, Medicare's share, and patient share Copy link
These figures use the same national baseline, with different participation and payment assumptions.
Computed from the Q4 2026 CMS release
- Allowed amount
- $418.85
- Medicare's share
- $335.08
- Sequestration
- -$6.70
- What Medicare pays
- $328.38
- Patient coinsurance
- $83.77
- Non-participating amount
- $397.91
- Limiting charge
- $457.60
The fee-schedule amount for 43239 in the Office (non-facility) setting. A participating provider accepts it as payment in full, and every figure below starts from it.
80% of the allowed amount, once the annual Part B deductible is met.
The 2% cut to Medicare’s share. It never reduces the allowed amount or the patient’s coinsurance.
Medicare’s share after sequestration.
The remaining 20%. Medigap or Medicaid often covers it.
What a provider who doesn’t participate in Medicare is allowed on an assigned claim: 95% of the allowed amount.
The most a non-participating provider can bill the patient on an unassigned claim: 115% of the non-participating amount.
National Q4 2026 figures at GPCI 1.000. Adjust for your locality and sequestration, or open the explanations below for each figure in full.
Is $418.85 what a practice actually receives?
It's the national allowed amount—the starting point. Medicare pays 80% of it ($335.08) and the patient owes 20% coinsurance ($83.77). Sequestration trims Medicare's share by about 2%, your locality's GPCIs scale the total up or down, and the expected-payment calculator applies all three. That payment is practice revenue that covers staff, space, equipment, and billing. It isn't the clinician's take-home pay. The practice-expense RVU above is CMS's estimate of that overhead share.
Sources: Budget Control Act sequestration provisions; CMS Medicare Fee-for-Service payment guidance; CMS Geographic Practice Cost Index (GPCI) files; CMS Physician Fee Schedule overview (cms.gov).
What's the non-participating amount for 43239?
$397.91 in the Office (non-facility) setting—95% of the $418.85 participating fee schedule amount above. A participating provider takes the fee schedule amount as payment in full on every claim. A non-participating provider is paid this reduced amount, but chooses claim by claim whether to accept assignment. See participating vs non-participating.
Sources: CMS Physician Fee Schedule overview (cms.gov); CMS Medicare Fee-for-Service payment guidance.
What's the limiting charge for 43239?
$457.60 in the Office (non-facility) setting—the ceiling on what a non-participating provider can bill the patient on an unassigned claim. That's 109.25% of the $418.85 amount above. The non-participating amount is 95% of the fee schedule rate ($397.91), and the statutory cap is 115% of that. See limiting charge.
Sources: CMS Physician Fee Schedule overview (cms.gov); CMS Medicare Fee-for-Service payment guidance.
Who’s billing it Copy link
The allowed amount depends on who bills the service: NPs and PAs get 85% of the fee schedule amount, social workers and counselors 75%. These are national Q4 2026 figures at GPCI 1.000.
| Billed by | Office (non-facility) | Facility |
|---|---|---|
| Physician (MD/DO) 100% The full fee schedule amount. Open in calculator | $418.85 | $123.58 |
| Physician assisting at surgery (-80, -81, -82) Medicare doesn’t pay for an assistant at surgery on this code. Source: Pub. 100-04 ch. 12 §20.4.3 Open in calculator | Not payable | Not payable |
A provider type is listed when it billed at least 1% of 43239’s Medicare services in CMS’s CY2024 Physician & Other Practitioners data. Each percentage applies before the 80/20 split and sequestration.
CMS RVU26DOctober 1 – December 31, 2026revision 2 See file rows
Which billing rules and modifiers apply? Copy link
Global period: what 43239's fee already covers Copy link
The fee covers pre-operative and post-operative work on the day of the procedure only—there is no follow-up window afterward. A visit the next day is separately payable.
| Modifier | Reports |
|---|---|
| -25 | A significant, separately identifiable E/M on the same day as the procedure, beyond its usual pre- and post-operative care. |
A modifier reports what happened; it does not by itself make a service payable. Documentation has to support it.
Billing policy Copy link
These billing-policy indicators explain how 43239 is treated. They apply whether the code is nationally priced or carrier-priced: a restriction like "bilateral not allowed" still matters on a carrier-priced code. See modifier amounts below for the dollar figures these support.
| Policy | Value | What it means |
|---|---|---|
| Bilateral surgery | 0 | No bilateral adjustment. The 150% bilateral payment adjustment does not apply to this procedure. |
| Assistant at surgery | 1 | Never separately payable. An assistant at surgery may never be separately paid for this procedure—a statutory restriction. |
| Co-surgeons | 0 | Not permitted. Medicare does not recognize co-surgeons (modifier 62) for this procedure. |
| Team surgery | 0 | Not permitted. Medicare does not recognize a surgical team (modifier 66) for this procedure. |
| Multiple procedures | 3 | Special endoscopic rules apply. This procedure is part of an endoscopic family; payment is based on the endoscopic base procedure rather than the standard multiple-procedure reduction. |
| Professional/technical split | 0 | No PC/TC split. This is a physician service code; the professional/technical split does not apply, and the code is billed as a single service. |
Modifier amounts: -26/TC, -50, -80/81/82, -AS, -62, -66 Copy link
National Office (non-facility) amounts for the modifiers this code's indicators support. These are single-line modifiers only. -51 (multiple-procedure reduction) depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one. Use the calculator for a locality-adjusted, sequestration-aware amount.
Not payable with 43239: -26/TC (professional/technical split); -50 (bilateral procedure); -80/81/82 (assistant surgeon (physician)); -AS (assistant at surgery (PA, NP, or CNS)); -62 (co-surgeons, each); -66 (team surgery).
Each amount applies a standard MPFS percentage (assistant surgeon 16%, non-physician assistant at surgery 13.6%, co-surgeon 62.5%, bilateral 150%) to the national Office (non-facility) amount above. CMS doesn't publish these as a column; Localis derives them, so check them against the current Medicare Claims Processing Manual before relying on them for payment.
CMS RVU26DOctober 1 – December 31, 2026revision 2 See file rows
Can you bill it with another code? Copy link
Check a pair of codes Copy link
Enter a second CPT or HCPCS code billed on the same date of service. We'll check the current NCCI procedure-to-procedure edit for the pair.
Billing together (NCCI edits) Copy link
NCCI Q4 2026Based on CMS's National Correct Coding Initiative (NCCI). A few examples appear here; use the complete edit page to check a specific pair.
Not separately payable with 43239 on the same date of service—no modifier bypasses the edit (modifier indicator 0)
Showing 3 of 118.
Separately payable with 43239 only when an NCCI-associated modifier is appropriate and documented (modifier indicator 1)
Showing 3 of 220.
Modifier 59 and the X modifiers are not a universal bypass—CMS expects the most specific applicable modifier, and which one that is depends on the pair and the documented circumstances.
Check a paired code or view all 338 NCCI pairs →
Medically Unlikely Edit (MUE) limit: 1 unit per patient per date of service.
Payment review for 43239 Copy link
Four published payment rules can change what 43239 allows on a claim: the office/facility differential, the same-day global package, the endoscopic base-code rule and the assistant-at-surgery prohibition. Each is a legitimate reason for a paid amount to differ from the fee-schedule amount on this page.
What to check
- Check the place-of-service code before attributing the gap to the payer: office and facility pricing differ by $295.27 nationally at GPCI 1.000, before any locality adjustment.
- Check the visit date: this code carries no follow-up window, so a related visit the day after the procedure is separately payable and should not have bundled.
- Check the other endoscopies on the claim: ranked below another scope in base code 43235’s family, this line pays its own $418.85 less that base code’s $322.65—$96.20 nationally at GPCI 1.000—rather than in full.
- Expect an assistant-at-surgery denial here rather than appealing it—a -80 or -AS line on this procedure is never separately payable.
- Reprice the line against the release, locality, setting, modifier and participation status that applied to the date of service before treating any difference as an underpayment.
Compare against 43238, 43240 and 43237: their amounts are in Related codes.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov); CMS Medicare Claims Processing Manual (Pub. 100-04); 42 USC 1395w-4(i)(2) (SSA §1848(i)(2))—Assistants-at-surgery.
How has it changed? Copy link
Rate history by release Copy link
National Office (non-facility) amount for 43239 across quarterly releases. +16.6% increase since Q1 2013 · peak $418.85 in Q1 2026
| Release | Status | Office | Facility |
|---|---|---|---|
| Q4 2026 Oct 1, 2026 – present | A | $418.85 (0.0% no change) | $123.58 (0.0% no change) |
| Q3 2026 Jul 1, 2026 – Sep 30, 2026 | A | $418.85 (0.0% no change) | $123.58 (0.0% no change) |
| Q2 2026 Apr 1, 2026 – Jun 30, 2026 | A | $418.85 (0.0% no change) | $123.58 (0.0% no change) |
| Q1 2026 Jan 1, 2026 – Mar 31, 2026 | A | $418.85 (+17.3% increase) | $123.58 (-6.8% decrease) |
| Q4 2025 Oct 1, 2025 – Dec 31, 2025 | A | $357.11 (0.0% no change) | $132.62 (0.0% no change) |
| Q3 2025 Jul 1, 2025 – Sep 30, 2025 | A | $357.11 (0.0% no change) | $132.62 (0.0% no change) |
| Q2 2025 Apr 1, 2025 – Jun 30, 2025 | A | $357.11 (0.0% no change) | $132.62 (0.0% no change) |
| Q1 2025 Jan 1, 2025 – Mar 31, 2025 | A | $357.11 (-4.9% decrease) | $132.62 (-2.8% decrease) |
| Q4 2024 Oct 1, 2024 – Dec 31, 2024 | A | $375.48 (0.0% no change) | $136.48 (0.0% no change) |
| Q3 2024 Jul 1, 2024 – Sep 30, 2024 | A | $375.48 (0.0% no change) | $136.48 (0.0% no change) |
| Q2 2024 Apr 1, 2024 – Jun 30, 2024 | A | $375.48 (0.0% no change) | $136.48 (0.0% no change) |
| Q1 2024 Mar 9, 2024 – Mar 31, 2024 | A | $375.48 (+1.7% increase) | $136.48 (+1.7% increase) |
| Q1 2024 Jan 1, 2024 – Mar 8, 2024 | A | $369.35 (-3.9% decrease) | $134.25 (-2.4% decrease) |
| Q4 2023 Oct 1, 2023 – Dec 31, 2023 | A | $384.28 (0.0% no change) | $137.58 (0.0% no change) |
| Q3 2023 Jul 1, 2023 – Sep 30, 2023 | A | $384.28 (0.0% no change) | $137.58 (0.0% no change) |
| Q2 2023 Apr 1, 2023 – Jun 30, 2023 | A | $384.28 (0.0% no change) | $137.58 (0.0% no change) |
| Q1 2023 Jan 1, 2023 – Mar 31, 2023 | A | $384.28 (-4.5% decrease) | $137.58 (-1.6% decrease) |
| Q4 2022 Oct 1, 2022 – Dec 31, 2022 | A | $402.47 (0.0% no change) | $139.81 (0.0% no change) |
| Q3 2022 Jul 1, 2022 – Sep 30, 2022 | A | $402.47 (0.0% no change) | $139.81 (0.0% no change) |
| Q2 2022 Apr 1, 2022 – Jun 30, 2022 | A | $402.47 (0.0% no change) | $139.81 (0.0% no change) |
| Q1 2022 Jan 1, 2022 – Mar 31, 2022 | A | $402.47 (+0.4% increase) | $139.81 (-0.3% decrease) |
| Q4 2021 Oct 1, 2021 – Dec 31, 2021 | A | $400.92 (0.0% no change) | $140.27 (0.0% no change) |
| Q3 2021 Jul 1, 2021 – Sep 30, 2021 | A | $400.92 (0.0% no change) | $140.27 (0.0% no change) |
| Q2 2021 Apr 1, 2021 – Jun 30, 2021 | A | $400.92 (0.0% no change) | $140.27 (0.0% no change) |
| Q1 2021 Jan 1, 2021 – Mar 31, 2021 | A | $400.92 (+4.5% increase) | $140.27 (-2.6% decrease) |
| Q4 2020 Oct 1, 2020 – Dec 31, 2020 | A | $383.63 (0.0% no change) | $144.00 (0.0% no change) |
| Q3 2020 Jul 1, 2020 – Sep 30, 2020 | A | $383.63 (0.0% no change) | $144.00 (0.0% no change) |
| Q2 2020 Apr 1, 2020 – Jun 30, 2020 | A | $383.63 (0.0% no change) | $144.00 (0.0% no change) |
| Q1 2020 Jan 1, 2020 – Mar 31, 2020 | A | $383.63 (+4.5% increase) | $144.00 (-1.3% decrease) |
| Q4 2019 Oct 1, 2019 – Dec 31, 2019 | A | $367.24 (0.0% no change) | $145.96 (0.0% no change) |
| Q3 2019 Jul 1, 2019 – Sep 30, 2019 | A | $367.24 (0.0% no change) | $145.96 (0.0% no change) |
| Q2 2019 Apr 1, 2019 – Jun 30, 2019 | A | $367.24 (0.0% no change) | $145.96 (0.0% no change) |
| Q1 2019 Jan 1, 2019 – Mar 31, 2019 | A | $367.24 (+4.3% increase) | $145.96 (-0.1% decrease) |
| Q4 2018 Oct 1, 2018 – Dec 31, 2018 | A | $352.08 (0.0% no change) | $146.16 (0.0% no change) |
| Q3 2018 Jul 1, 2018 – Sep 30, 2018 | A | $352.08 (0.0% no change) | $146.16 (0.0% no change) |
| Q2 2018 Apr 1, 2018 – Jun 30, 2018 | A | $352.08 (0.0% no change) | $146.16 (0.0% no change) |
| Q1 2018 Jan 1, 2018 – Mar 31, 2018 | A | $352.08 (+0.8% increase) | $146.16 (-0.2% decrease) |
| Q4 2017 Oct 1, 2017 – Dec 31, 2017 | A | $349.20 (0.0% no change) | $146.43 (0.0% no change) |
| Q3 2017 Jul 1, 2017 – Sep 30, 2017 | A | $349.20 (0.0% no change) | $146.43 (0.0% no change) |
| Q2 2017 Apr 1, 2017 – Jun 30, 2017 | A | $349.20 (0.0% no change) | $146.43 (0.0% no change) |
| Q1 2017 Jan 1, 2017 – Mar 31, 2017 | A | $349.20 (-13.5% decrease) | $146.43 (-3.3% decrease) |
| Q4 2016 Oct 1, 2016 – Dec 31, 2016 | A | $403.87 (0.0% no change) | $151.45 (0.0% no change) |
| Q3 2016 Jul 1, 2016 – Sep 30, 2016 | A | $403.87 (0.0% no change) | $151.45 (0.0% no change) |
| Q2 2016 Apr 1, 2016 – Jun 30, 2016 | A | $403.87 (0.0% no change) | $151.45 (0.0% no change) |
| Q1 2016 Jan 1, 2016 – Mar 31, 2016 | A | $403.87 (-2.1% decrease) | $151.45 (-1.8% decrease) |
| Q4 2015 Oct 1, 2015 – Dec 31, 2015 | A | $412.52 (+0.5% increase) | $154.15 (+0.5% increase) |
| Q3 2015 Jul 1, 2015 – Sep 30, 2015 | A | $410.46 (0.0% no change) | $153.39 (0.0% no change) |
| Q2 2015 Apr 1, 2015 – Jun 30, 2015 | A | $410.46 (0.0% no change) | $153.39 (0.0% no change) |
| Q1 2015 Jan 1, 2015 – Mar 31, 2015 | A | $410.46 (+1.2% increase) | $153.39 (+0.7% increase) |
| Q4 2014 Oct 1, 2014 – Dec 31, 2014 | A | $405.51 (0.0% no change) | $152.25 (0.0% no change) |
| Q3 2014 Jul 1, 2014 – Sep 30, 2014 | A | $405.51 (0.0% no change) | $152.25 (0.0% no change) |
| Q2 2014 Apr 1, 2014 – Jun 30, 2014 | A | $405.51 (+12.9% increase) | $152.25 (-12.8% decrease) |
| Q2 2013 Apr 1, 2013 – Jun 30, 2013 | A | $359.28 (0.0% no change) | $174.54 (0.0% no change) |
| Q1 2013 Jan 1, 2013 – Mar 31, 2013 | A | $359.28 | $174.54 |
Why 43239's rate changed Copy link
National baseline (GPCI 1.000) · Office (non-facility) · Before sequestration
43239's national amount rose $59.57 (+16.6%), from $359.28 in Q1 2013 to $418.85 in Q4 2026. Changes to the conversion factor, which CMS sets for every code, took $6.57 off. CMS revaluing 43239 itself added $66.14: +$89.19 from practice-expense RVUs, −$18.04 from work RVUs and −$5.01 from malpractice RVUs. The most recent change came in Q1 2026: +$61.74 (+17.3%), with +$52.77 from practice-expense RVUs, +$11.64 from the conversion factor, −$2.00 from work RVUs and −$0.67 from malpractice RVUs.
| Release | Change | Conversion factor | Work RVUs | PE RVUs | MP RVUs |
|---|---|---|---|---|---|
| Q1 2026 from Q4 2025 | +$61.74 $357.11 → $418.85 | +$11.64 $32.3465 → $33.4009 | −$2.00 | +$52.77 | −$0.67 |
| Q1 2025 from Q4 2024 | −$18.37 $375.48 → $357.11 | −$10.61 $33.2875 → $32.3465 | $0.00 | −$7.44 | −$0.32 |
| Q1 2024 (from Mar 9) from Q1 2024 (from Jan 1) | +$6.13 $369.35 → $375.48 | +$6.13 $32.7442 → $33.2875 | $0.00 | $0.00 | $0.00 |
| Q1 2024 (from Jan 1) from Q4 2023 | −$14.93 $384.28 → $369.35 | −$12.97 $33.8872 → $32.7442 | $0.00 | −$2.29 | +$0.33 |
| Q1 2023 from Q4 2022 | −$18.19 $402.47 → $384.28 | −$8.36 $34.6062 → $33.8872 | $0.00 | −$10.51 | +$0.68 |
| Q1 2022 from Q4 2021 | +$1.55 $400.92 → $402.47 | −$3.30 $34.8931 → $34.6062 | $0.00 | +$4.50 | +$0.35 |
| Q1 2021 from Q4 2020 | +$17.29 $383.63 → $400.92 | −$12.72 $36.0896 → $34.8931 | $0.00 | +$30.71 | −$0.70 |
| Q1 2020 from Q4 2019 | +$16.39 $367.24 → $383.63 | +$0.51 $36.0391 → $36.0896 | $0.00 | +$17.32 | −$1.44 |
| Q1 2019 from Q4 2018 | +$15.16 $352.08 → $367.24 | +$0.39 $35.9996 → $36.0391 | $0.00 | +$14.41 | +$0.36 |
| Q1 2018 (from Jan 1) from Q4 2017 | +$2.88 $349.20 → $352.08 | +$1.08 $35.8887 → $35.9996 | $0.00 | +$2.16 | −$0.36 |
| Q1 2017 from Q4 2016 | −$54.67 $403.87 → $349.20 | +$0.95 $35.8043 → $35.8887 | −$3.59 | −$51.31 | −$0.72 |
| Q1 2016 from Q4 2015 | −$8.65 $412.52 → $403.87 | −$1.48 $35.9335 → $35.8043 | $0.00 | −$6.45 | −$0.72 |
| Q4 2015 from Q3 2015 | +$2.06 $410.46 → $412.52 | +$2.06 $35.7547 → $35.9335 | $0.00 | $0.00 | $0.00 |
| Q1 2015 from Q4 2014 | +$4.95 $405.51 → $410.46 | −$0.77 $35.8228 → $35.7547 | +$0.72 | +$4.28 | +$0.72 |
| Q2 2014 from Q2 2013 | +$46.23 $359.28 → $405.51 | +$19.01 $34.0230 → $35.8228 | −$14.33 | +$44.42 | −$2.87 |
CMS doesn't publish this split; we derive it from each release's RVUs and conversion factor. We apply the new conversion factor to the earlier RVUs first, then price each RVU change at the new conversion factor. Another order would move a few cents between columns, but every total stays the same.
This amount has been unchanged since Q1 2026, when it increased 17.3%.
When does this rate change?
CMS publishes a fee schedule release every quarter (January, April, July, October), and each is versioned here. See what changed each release, or get an email when a new release moves rates.
The 43239 rate last moved in Q1 2026. See its rate history.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files.
Usage and related codes Copy link
How often 43239 is billed Copy link
Across Original Medicare in CY2024, 43239 ranked #84 of the 7,879 CPT codes billed to Medicare that year, by patients served or total allowed dollars.
2024 Medicare fee-for-service national totals. They exclude Medicare Advantage, Medicaid and commercial volume, so real-world use runs higher. This is a calendar-year snapshot from the CMS Physician & Other Practitioners dataset, on a different cycle from the Q4 2026 fee schedule above.
Who bills 43239 to Medicare
Observed CY2024 Medicare fee-for-service billing, by the rendering clinician's CMS specialty. Each share is that specialty's slice of all observed services for this code that year.
Setting split that year: 5% Office (non-facility) · 95% facility. CMS publishes only this facility vs non-facility split, never the exact place of service. The Office (non-facility) figure does not identify urgent care or any other specific setting.
CY2024 Medicare fee-for-service only, from the CMS Physician & Other Practitioners dataset, which suppresses rows under 11 beneficiaries. We omit specialty groups with fewer than 30 observed clinicians, so the shares can fall short of 100%. Specialty and practice-type pages linked elsewhere on this page are curated code lists, not utilization claims.
How 43239 compares with other codes Copy link
Against every code with a national PFS amount in Q4 2026 · National baseline · Before sequestration
- +238.9% Office over facility
- 43239's Office amount is $295.27 more than its facility amount, because a facility bills its own overhead separately. Of the 7,745 codes priced in both settings, 2,167 have a higher Office amount. 43239's gap is larger than 80% of theirs; the median gap is +78.1%.
- 55.0% Highest vs. lowest locality
- 43239's Office amount is 55.0% higher in its highest-paid payment locality than in its lowest. That spread is wider than 81% of the 7,716 codes compared; the median spread is 43.6%. How much a code's amount varies by locality depends on its mix of work, practice-expense and malpractice RVUs, since each has its own GPCI.
- +16.6% Since Q1 2013
- 43239's Office amount rose 16.6% from Q1 2013 to Q4 2026. Over the same period, the median code's amount fell 6.6%. That's higher than the change for 92% of the 6,418 codes priced in both releases.
These comparisons cover every code with a national Physician Fee Schedule amount: status A, R or T, with no blank RVUs. The locality comparison leaves out codes with an OPPS cap, because the cap, not the GPCIs, can set their amount in some localities.
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Source & method
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This page uses CMS's Medicare Physician Fee Schedule Q4 2026 release (effective October 2026). National baselines use GPCI 1.000 and exclude sequestration. Whether a national amount exists depends on the status and CMS’s payment instructions; blank RVUs are never treated as zero. Past releases are never edited, so these sources stay valid after CMS publishes a newer one. The commercial rates above are the only figures on this page that CMS did not publish. Payers published them in their own Transparency in Coverage files. Modifier amounts apply standard MPFS percentages to this code's billing indicators. We derive them here rather than read them from CMS, so confirm them against the current Claims Processing Manual before relying on them for payment. Our methodology explains sourcing, parsing, versioning, and how we cross-check claims before we publish them.
Localis context written from primary sources: CMS Medicare Physician Fee Schedule Relative Value Files. Not derived from AMA CPT descriptor text.
Conversion factor $33.4009 read from the same file, row 5,167, column 26.
The price card’s citations show the exact row, columns, and file lines behind each amount.
Cite this rate
The citation names the release, so anyone can check it even after CMS publishes a newer one.
CPT 43239 National PFS baseline: Office (non-facility) $418.85; Facility $123.58 (Q4 2026; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU26D, PPRRVU2026_Oct_nonQPP.csv row 5,167. Localis. https://localishealth.com/cpt/43239/2026/D