Question 1

Is an upper GI endoscopy covered by Medicare?

Accepted Answer

Yes. Medicare Part B covers upper GI endoscopy (esophagogastroduodenoscopy, or EGD) when medically necessary — for evaluation of symptoms such as chronic heartburn, difficulty swallowing, upper abdominal pain, or unexplained weight loss. The most common diagnostic code is CPT 43239 (EGD with biopsy). Medicare pays 80% of the approved amount after the $283 annual Part B deductible. Routine screening EGD is not covered (unlike colonoscopy).

Question 2

What is the Medicare cost for an upper endoscopy without Medigap?

Accepted Answer

In 2026, the Medicare-approved amounts for EGD with biopsy (CPT 43239) are approximately: surgeon fee $261 (your 20%: $52), HOPD facility fee $872 (your 20%: $174), or ASC facility fee $589 (your 20%: $118). Anesthesia adds $150–$300 (your 20%: $30–$60). Total out-of-pocket at an ASC without Medigap: approximately $200–$230. With Medigap Plan G, your cost is $0 after the $283 annual deductible.

Question 3

Does Medicare cover upper endoscopy at an ASC?

Accepted Answer

Yes. Upper GI endoscopy is one of the most commonly performed procedures in ambulatory surgery centers, and Medicare fully covers it at an ASC under the same Part B rules as HOPD. The ASC facility fee ($589) is approximately 32% lower than the HOPD fee ($872), saving you $57 in 20% coinsurance. If your gastroenterologist performs endoscopies at an ASC, choosing that setting instead of a hospital outpatient department will reduce your cost.

Question 4

Why does this calculator show a different amount than Medicare.gov's cost estimate?

Accepted Answer

This calculator may show a higher number than Medicare.gov's "Patient Pays (average)" for several reasons: (1) Deductible timing — this calculator applies the $283 Part B annual deductible if it has not yet been met; Medicare.gov's average assumes many patients have already satisfied theirs. (2) Anesthesia — Medicare.gov's estimate covers the facility fee and surgeon only; anesthesia is billed separately and is included in this calculator. (3) Location adjustment — surgeon fees are adjusted by your region's Geographic Practice Cost Index (GPCI); in high-cost cities like Seattle or New York, surgeon fees run 30–50% above the national rate. Facility fees (HOPD and ASC) are nationally fixed by CMS and should match Medicare.gov exactly. (4) Patient mix — Medicare.gov's "Patient Pays" average includes Medigap enrollees who pay $0 coinsurance, which pulls the reported average below what uninsured Original Medicare patients typically pay.

Cost Component	Medicare-Approved Amount	Your Share (20%)
Surgeon Fee — Upper GI Endoscopy (CPT 43239)	$123	$25
Hospital Outpatient (HOPD) Facility Fee	$926	$185
Ambulatory Surgery Center (ASC) Facility Fee	$497	$99
Anesthesia (estimated)	$150–$300	20% of approved

Medicare Upper GI Endoscopy Cost 2026 | Out-of-Pocket Estimator

2026 Medicare Cost Summary — Upper GI Endoscopy (CPT 43239)

What Medicare Pays

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