CPT code 42800: Biopsy, pharynx tissue sampling2026 Medicare rate & RVUs in Los Angeles, CA
Reports sampling of a suspected pharyngeal lesion for tissue diagnosis, typically by an otolaryngologist during office evaluation or an operative examination.
In Los Angeles, CA, Medicare pays $178.59 for 42800 in the office and $115.37 when it’s performed in a hospital or facility.
Check a contract rate as a % of Medicare · 42800 nationwide
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 11 sections
What 42800 covers
An otolaryngologist takes a tissue sample from an abnormal area of the pharynx for diagnostic examination. The service is used when inspection identifies a lesion or mucosal change that needs tissue diagnosis; the biopsy samples tissue rather than removing the lesion as definitive treatment. It may be performed in an office or an operating room, depending on access and the clinical circumstances.
Report the code when the documented service is a pharyngeal biopsy, not a biopsy of a nasopharyngeal lesion or therapeutic excision. The record should identify the pharyngeal site, the abnormality prompting sampling, and the tissue obtained. Medicare assigns a 10-day global period, which includes related postoperative visits during that period. For multiple procedures in one session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% reduction. Do not use modifier 50 for bilateral adjustment. Medicare does not pay an assistant at surgery for this service; co-surgeons and team surgery are not permitted.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
How Los Angeles, CA compares for 42800
Across 109 of 109 payment localities, the office rate for 42800 runs from $141.33 in Arkansas to $208.34 in San Benito County, CA. Los Angeles, CA pays $178.59. The RVUs are the same everywhere; the geographic indexes change the dollars.
- Los Angeles, CA · this page$178.59
- Bakersfield, CA · California$167.97−$10.62
- Chico, CA · California$167.36−$11.23
- El Centro, CA · California$167.40−$11.19
- Fresno, CA · California$167.36−$11.23
- Hanford, CA · California$167.36−$11.23
- Madera, CA · California$167.36−$11.23
Other areas in California first, then benchmark localities. Bars start at $0.
Every other payment area
| Payment locality | Office | Facility |
|---|---|---|
| Merced, CACalifornia | $167.36 | $108.79 |
| Modesto, CACalifornia | $167.36 | $108.79 |
| Napa, CACalifornia | $192.82 | $122.39 |
| Oxnard, CACalifornia | $177.59 | $114.42 |
| Redding, CACalifornia | $167.36 | $108.79 |
| Rest of CaliforniaCalifornia | $167.36 | $108.79 |
| Riverside, CACalifornia | $169.63 | $111.06 |
| Sacramento, CACalifornia | $175.34 | $113.19 |
| Salinas, CACalifornia | $174.69 | $112.75 |
| San Diego, CACalifornia | $178.60 | $114.68 |
| Marin County, CACalifornia | $203.72 | $128.36 |
| San Francisco, CACalifornia | $203.48 | $128.12 |
| San Benito County, CACalifornia | $208.34 | $131.28 |
| Santa Clara County, CACalifornia | $207.37 | $130.31 |
| San Luis Obispo, CACalifornia | $171.91 | $111.04 |
| Santa Cruz, CACalifornia | $180.15 | $115.22 |
| Santa Maria, CACalifornia | $175.29 | $112.97 |
| Santa Rosa, CACalifornia | $181.95 | $116.32 |
| Stockton, CACalifornia | $167.36 | $108.79 |
| Vallejo, CACalifornia | $192.48 | $122.04 |
| Visalia, CACalifornia | $167.36 | $108.79 |
| Yuba City, CACalifornia | $167.36 | $108.79 |
| Washington, DC areaDistrict of Columbia | $181.82 | $118.87 |
| Miami, FLFlorida | $174.72 | $119.09 |
| Chicago, ILIllinois | $169.60 | $115.89 |
| Manhattan, NYNew York | $183.91 | $121.81 |
| AlaskaAlaska | $186.77 | $129.85 |
| AlabamaAlabama | $143.38 | $96.62 |
| ArkansasArkansas | $141.33 | $95.42 |
| ArizonaArizona | $155.36 | $103.58 |
| ColoradoColorado | $165.46 | $108.60 |
| ConnecticutConnecticut | $170.22 | $112.66 |
| DelawareDelaware | $157.91 | $105.11 |
| Fort Lauderdale, FLFlorida | $166.70 | $112.56 |
| Rest of FloridaFlorida | $158.53 | $107.44 |
| Atlanta, GAGeorgia | $162.90 | $108.60 |
| Rest of GeorgiaGeorgia | $149.57 | $101.90 |
| Hawaii, Guam, HIHawaii | $171.21 | $110.45 |
| IowaIowa | $146.43 | $97.53 |
| IdahoIdaho | $147.49 | $98.32 |
| East St. Louis, ILIllinois | $158.30 | $109.13 |
| Rest of IllinoisIllinois | $154.39 | $105.60 |
| Suburban Chicago, ILIllinois | $168.26 | $113.37 |
| IndianaIndiana | $148.32 | $98.78 |
| KansasKansas | $146.01 | $97.70 |
| KentuckyKentucky | $147.31 | $99.80 |
| New Orleans, LALouisiana | $154.36 | $104.07 |
| Rest of LouisianaLouisiana | $147.19 | $99.89 |
| Metropolitan Boston, MAMassachusetts | $181.34 | $117.53 |
| Rest of MassachusettsMassachusetts | $164.59 | $108.32 |
| Baltimore area, MDMaryland | $169.80 | $112.45 |
| Rest of MarylandMaryland | $160.82 | $106.74 |
| Rest of MaineMaine | $148.53 | $99.37 |
| Southern Maine, MEMaine | $156.12 | $103.15 |
| Detroit, MIMichigan | $160.76 | $109.19 |
| Rest of MichiganMichigan | $151.35 | $102.56 |
| MinnesotaMinnesota | $157.79 | $102.80 |
| Metropolitan Kansas City, MOMissouri | $153.04 | $102.85 |
| Metropolitan St. Louis, MOMissouri | $154.59 | $103.71 |
| Rest of MissouriMissouri | $144.86 | $98.80 |
| MississippiMississippi | $143.11 | $97.10 |
| MontanaMontana | $159.64 | $106.20 |
| North CarolinaNorth Carolina | $150.03 | $100.17 |
| North DakotaNorth Dakota | $155.49 | $102.05 |
| NebraskaNebraska | $147.14 | $97.81 |
| New HampshireNew Hampshire | $163.12 | $107.49 |
| Northern New JerseyNew Jersey | $180.02 | $118.03 |
| Rest of New JerseyNew Jersey | $171.95 | $113.59 |
| New MexicoNew Mexico | $152.28 | $103.27 |
| NevadaNevada | $158.59 | $105.10 |
| NYC suburbs and Long Island, NYNew York | $188.67 | $125.13 |
| Poughkeepsie and northern NYC suburbs, NYNew York | $173.29 | $114.77 |
| Queens, NYNew York | $185.02 | $121.85 |
| Rest of New YorkNew York | $152.28 | $101.51 |
| OhioOhio | $150.50 | $101.71 |
| OklahomaOklahoma | $146.76 | $99.04 |
| Portland, OROregon | $170.36 | $110.99 |
| Rest of OregonOregon | $157.15 | $103.92 |
| Metropolitan Philadelphia, PAPennsylvania | $166.19 | $110.56 |
| Rest of PennsylvaniaPennsylvania | $150.59 | $101.53 |
| Puerto RicoPuerto Rico | $160.72 | $106.69 |
| Rhode IslandRhode Island | $163.28 | $108.08 |
| South CarolinaSouth Carolina | $150.56 | $101.18 |
| South DakotaSouth Dakota | $155.00 | $101.56 |
| TennesseeTennessee | $146.77 | $98.20 |
| Austin, TXTexas | $165.09 | $108.55 |
| Beaumont, TXTexas | $149.63 | $101.00 |
| Brazoria, TXTexas | $157.53 | $104.57 |
| Dallas, TXTexas | $158.66 | $105.43 |
| Fort Worth, TXTexas | $157.69 | $105.00 |
| Galveston, TXTexas | $158.08 | $105.02 |
| Houston, TXTexas | $161.93 | $108.86 |
| Rest of TexasTexas | $153.58 | $102.86 |
| UtahUtah | $152.59 | $102.35 |
| VirginiaVirginia | $155.79 | $103.26 |
| Virgin Islands, VIUnited States Virgin Islands | $160.72 | $106.69 |
| VermontVermont | $155.13 | $102.23 |
| Rest of WashingtonWashington | $164.20 | $107.93 |
| King County, WAWashington | $184.75 | $119.17 |
| WisconsinWisconsin | $150.36 | $99.16 |
| West VirginiaWest Virginia | $148.81 | $102.37 |
| WyomingWyoming | $157.83 | $104.39 |
42800 rates by state
Office rate range in each state. Select a state to see its payment localities.
Explore a state
Local rates. Clear comparisons.
Hover or focus a tile to see its rate range. Select it to open the state’s fee schedule.
$141.33
$187.85
Color shows the midpoint of each state’s locality range.
View every state and territory as a table
| State / territory | Office rate range | Localities |
|---|---|---|
| AK | $186.77 | 1 |
| AL | $143.38 | 1 |
| AR | $141.33 | 1 |
| AZ | $155.36 | 1 |
| CA | $167.36–$208.34 | 29 |
| CO | $165.46 | 1 |
| CT | $170.22 | 1 |
| DC | $181.82 | 1 |
| DE | $157.91 | 1 |
| FL | $158.53–$174.72 | 3 |
| GA | $149.57–$162.90 | 2 |
| GU | $171.21 | 1 |
| HI | $171.21 | 1 |
| IA | $146.43 | 1 |
| ID | $147.49 | 1 |
| IL | $154.39–$169.60 | 4 |
| IN | $148.32 | 1 |
| KS | $146.01 | 1 |
| KY | $147.31 | 1 |
| LA | $147.19–$154.36 | 2 |
| MA | $164.59–$181.34 | 2 |
| MD | $160.82–$181.82 | 3 |
| ME | $148.53–$156.12 | 2 |
| MI | $151.35–$160.76 | 2 |
| MN | $157.79 | 1 |
| MO | $144.86–$154.59 | 3 |
| MS | $143.11 | 1 |
| MT | $159.64 | 1 |
| NC | $150.03 | 1 |
| ND | $155.49 | 1 |
| NE | $147.14 | 1 |
| NH | $163.12 | 1 |
| NJ | $171.95–$180.02 | 2 |
| NM | $152.28 | 1 |
| NV | $158.59 | 1 |
| NY | $152.28–$188.67 | 5 |
| OH | $150.50 | 1 |
| OK | $146.76 | 1 |
| OR | $157.15–$170.36 | 2 |
| PA | $150.59–$166.19 | 2 |
| PR | $160.72 | 1 |
| RI | $163.28 | 1 |
| SC | $150.56 | 1 |
| SD | $155.00 | 1 |
| TN | $146.77 | 1 |
| TX | $149.63–$165.09 | 8 |
| UT | $152.59 | 1 |
| VA | $155.79–$181.82 | 2 |
| VI | $160.72 | 1 |
| VT | $155.13 | 1 |
| WA | $164.20–$184.75 | 2 |
| WI | $150.36 | 1 |
| WV | $148.81 | 1 |
| WY | $157.83 | 1 |
How the 42800 rate is calculated
Each of 42800’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 42800
RVUs × geographic indexes × conversion factor
Work1.40
1.40 RVUs× 1.000 GPCI
Practice expense3.17
3.17 RVUs× 1.000 GPCI
Malpractice0.21
0.21 RVUs× 1.000 GPCI
Adjusted RVUs
4.7800
Conversion factor
$33.4009
Medicare rate
$159.66
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
The exact Los Angeles, CA inputs and CMS source lines
PPRRVU2026_Oct_nonQPP.csv
5,071
- Code
- 42800
- Physician work
- 1.40
- Practice expense
- 3.17
- Malpractice
- 0.21
GPCI2026.csv
13
- Locality
- Los Angeles, CA
- Physician work
- 1.041
- Practice expense
- 1.183
- Malpractice
- 0.664
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 1.40 | × 1.041 | 1.4574 |
| Practice expense | 3.17 | × 1.183 | 3.7501 |
| Malpractice | 0.21 | × 0.664 | 0.1394 |
| Total RVUs | 5.3469 | ||
| Conversion factor | × 33.4009 | ||
Office rate, Los Angeles, CA$178.59
Office: (1.4 × 1.041 + 3.17 × 1.183 + 0.21 × 0.664) × $33.4009 = $178.59
Facility: (1.4 × 1.041 + 1.57 × 1.183 + 0.21 × 0.664) × $33.4009 = $115.37
Payment rules and modifiers for 42800
42800 has a 10-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42800
Biopsy, pharynx tissue sampling
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 010 | Minor procedure: the day of the procedure plus 10 days after are included. |
| Multiple procedures | 2 | Standard reduction: highest-valued procedure at 100%, others at 50%. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 1 | Not paid (statutory restriction). |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
| Split (54/55/56) | 0.10/0.80/0.10 | Share of the payment for pre-op, the procedure itself, and post-op care. |
Global surgery period · 42800
Biopsy, pharynx tissue sampling
10-day global period ends
Oct 11, 2026
Covers Oct 1, 2026 through Oct 11, 2026 (11 days).
Visit on Oct 31, 2026
After the global period ends: visits and procedures are billed normally.
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
42800 without 51 · national office
$159.66
Biopsy, pharynx tissue sampling
42800-51 · Second procedure: 50%
$79.83
When this isn’t the highest-valued procedure in the session, Medicare pays 50% of its fee schedule amount (the highest is paid at 100%).
How 42800 has changed in Los Angeles, CA
42800 · Office / nonfacility
$178.59
Effective 2026-10-01
The base rate is $5.64 higher than on 2025-10-01, moving from $172.95 to $178.59 (3.3%).
It is unchanged from the immediately preceding available release, effective 2026-07-01.
One bar per available release, ordered by effective date. Missing rates remain gaps. These comparisons hold the code, setting and locality identifiers constant; they do not isolate which policy or input caused a change.
What changed, release by release
January 1, 2026
RVU26A
$172.95changed to$178.59
- Conversion factor 32.3465 changed to 33.4009
- Work RVU 1.44 changed to 1.40
- Practice expense RVU 3.10 changed to 3.17
- Work GPCI 1.042 changed to 1.041
- Practice expense GPCI 1.194 changed to 1.183
- Malpractice GPCI 0.690 changed to 0.664
Held through RVU26B, RVU26C, RVU26D.
January 1, 2025
RVU25A
$179.97changed to$172.95
- Conversion factor 33.2875 changed to 32.3465
- Practice expense RVU 3.15 changed to 3.10
Held through RVU25B, RVU25C, RVU25D.
March 9, 2024
RVU24AR
$177.03changed to$179.97
- Conversion factor 32.7442 changed to 33.2875
Held through RVU24B, RVU24C, RVU24D.
January 1, 2024
RVU24A
$181.99changed to$177.03
- Conversion factor 33.8872 changed to 32.7442
- Practice expense RVU 3.14 changed to 3.15
- Malpractice RVU 0.20 changed to 0.21
- Work GPCI 1.045 changed to 1.042
- Practice expense GPCI 1.185 changed to 1.194
- Malpractice GPCI 0.724 changed to 0.690
January 1, 2023
RVU23A
$183.11changed to$181.99
- Conversion factor 34.6062 changed to 33.8872
- Practice expense RVU 3.09 changed to 3.14
- Work GPCI 1.048 changed to 1.045
- Practice expense GPCI 1.175 changed to 1.185
- Malpractice GPCI 0.757 changed to 0.724
Held through RVU23B, RVU23C, RVU23D.
January 1, 2022
RVU22A
$182.99changed to$183.11
- Conversion factor 34.8931 changed to 34.6062
- Practice expense RVU 3.05 changed to 3.09
Held through RVU22B, RVU22C, RVU22D.
January 1, 2021
RVU21A
$180.77changed to$182.99
- Conversion factor 36.0896 changed to 34.8931
- Practice expense RVU 2.86 changed to 3.05
- Malpractice RVU 0.19 changed to 0.20
- Work GPCI 1.047 changed to 1.048
- Practice expense GPCI 1.176 changed to 1.175
- Malpractice GPCI 0.725 changed to 0.757
Held through RVU21B, RVU21C, RVU21D.
January 1, 2020
RVU20A
$180.43changed to$180.77
- Conversion factor 36.0391 changed to 36.0896
- Practice expense RVU 2.85 changed to 2.86
- Malpractice RVU 0.21 changed to 0.19
- Work GPCI 1.046 changed to 1.047
- Practice expense GPCI 1.177 changed to 1.176
- Malpractice GPCI 0.694 changed to 0.725
Held through RVU20B, RVU20C, RVU20D.
January 1, 2019
RVU19A
$179.81changed to$180.43
- Conversion factor 35.9996 changed to 36.0391
- Practice expense RVU 2.84 changed to 2.85
Held through RVU19B, RVU19C, RVU19D.
January 1, 2018
RVU18AR1
$181.81changed to$179.81
- Conversion factor 35.8887 changed to 35.9996
- Practice expense RVU 2.90 changed to 2.84
- Work GPCI 1.047 changed to 1.046
- Practice expense GPCI 1.169 changed to 1.177
- Malpractice GPCI 0.801 changed to 0.694
Held through RVU18B, RVU18C, RVU18D.
January 1, 2017
RVU17A
$183.85changed to$181.81
- Conversion factor 35.8043 changed to 35.8887
- Practice expense RVU 2.96 changed to 2.90
- Practice expense GPCI 1.161 changed to 1.169
- Malpractice GPCI 0.908 changed to 0.801
Held through RVU17B, RVU17C, RVU17D.
January 1, 2016
RVU16A
$184.01changed to$183.85
- Conversion factor 35.9335 changed to 35.8043
- Practice expense RVU 2.94 changed to 2.96
- Malpractice RVU 0.22 changed to 0.21
Held through RVU16B, RVU16C, RVU16D.
July 1, 2015
RVU15C
$183.09changed to$184.01
- Conversion factor 35.7547 changed to 35.9335
Held through RVU15D.
January 1, 2015
RVU15A
$182.65changed to$183.09
- Conversion factor 35.8228 changed to 35.7547
- Practice expense RVU 2.98 changed to 2.94
- Malpractice RVU 0.19 changed to 0.22
- Work GPCI 1.042 changed to 1.047
- Practice expense GPCI 1.158 changed to 1.161
- Malpractice GPCI 0.775 changed to 0.908
Held through RVU15B.
January 1, 2014
RVU14A
$185.08changed to$182.65
- Conversion factor 34.0230 changed to 35.8228
- Practice expense RVU 3.31 changed to 2.98
- Malpractice RVU 0.20 changed to 0.19
- Work GPCI 1.036 changed to 1.042
- Practice expense GPCI 1.154 changed to 1.158
- Malpractice GPCI 0.642 changed to 0.775
Held through RVU14B, RVU14C, RVU14D.
October 1, 2013
RVU13D
No ratechanged to$185.08
January 1, 2013
RVU13AR
Earliest loaded release: No rate
Held through RVU13B, RVU13C.
| Effective from | Office | Facility | CMS release |
|---|---|---|---|
| 2026-10-01 | $178.59 | $115.37 | RVU26D |
| 2026-07-01 | $178.59 | $115.37 | RVU26C |
| 2026-04-01 | $178.59 | $115.37 | RVU26B |
| 2026-01-01 | $178.59 | $115.37 | RVU26A |
| 2025-10-01 | $172.95 | $127.76 | RVU25D |
| 2025-07-01 | $172.95 | $127.76 | RVU25C |
| 2025-04-01 | $172.95 | $127.76 | RVU25B |
| 2025-01-01 | $172.95 | $127.76 | RVU25A |
| 2024-10-01 | $179.97 | $130.29 | RVU24D |
| 2024-07-01 | $179.97 | $130.29 | RVU24C |
| 2024-04-01 | $179.97 | $130.29 | RVU24B |
| 2024-03-09 | $179.97 | $130.29 | RVU24AR |
| 2024-01-01 | $177.03 | $128.16 | RVU24A |
| 2023-10-01 | $181.99 | $130.59 | RVU23D |
| 2023-07-01 | $181.99 | $130.59 | RVU23C |
| 2023-04-01 | $181.99 | $130.59 | RVU23B |
| 2023-01-01 | $181.99 | $130.59 | RVU23A |
| 2022-10-01 | $183.11 | $129.84 | RVU22D |
| 2022-07-01 | $183.11 | $129.84 | RVU22C |
| 2022-04-01 | $183.11 | $129.84 | RVU22B |
| 2022-01-01 | $183.11 | $129.84 | RVU22A |
| 2021-10-01 | $182.99 | $127.23 | RVU21D |
| 2021-07-01 | $182.99 | $127.23 | RVU21C |
| 2021-04-01 | $182.99 | $127.23 | RVU21B |
| 2021-01-01 | $182.99 | $127.23 | RVU21A |
| 2020-10-01 | $180.77 | $126.86 | RVU20D |
| 2020-07-01 | $180.77 | $126.86 | RVU20C |
| 2020-04-01 | $180.77 | $126.86 | RVU20B |
| 2020-01-01 | $180.77 | $126.86 | RVU20A |
| 2019-10-01 | $180.43 | $126.56 | RVU19D |
| 2019-07-01 | $180.43 | $126.56 | RVU19C |
| 2019-04-01 | $180.43 | $126.56 | RVU19B |
| 2019-01-01 | $180.43 | $126.56 | RVU19A |
| 2018-10-01 | $179.81 | $124.72 | RVU18D |
| 2018-07-01 | $179.81 | $124.72 | RVU18C |
| 2018-04-01 | $179.81 | $124.72 | RVU18B |
| 2018-01-01 | $179.81 | $124.72 | RVU18AR1 |
| 2017-10-01 | $181.81 | $126.43 | RVU17D |
| 2017-07-01 | $181.81 | $126.43 | RVU17C |
| 2017-04-01 | $181.81 | $126.43 | RVU17B |
| 2017-01-01 | $181.81 | $126.43 | RVU17A |
| 2016-10-01 | $183.85 | $127.73 | RVU16D |
| 2016-07-01 | $183.85 | $127.73 | RVU16C |
| 2016-04-01 | $183.85 | $127.73 | RVU16B |
| 2016-01-01 | $183.85 | $127.73 | RVU16A |
| 2015-10-01 | $184.01 | $128.10 | RVU15D |
| 2015-07-01 | $184.01 | $128.10 | RVU15C |
| 2015-04-01 | $183.09 | $127.47 | RVU15B |
| 2015-01-01 | $183.09 | $127.47 | RVU15A |
| 2014-10-01 | $182.65 | $127.06 | RVU14D |
| 2014-07-01 | $182.65 | $127.06 | RVU14C |
| 2014-04-01 | $182.65 | $127.06 | RVU14B |
| 2014-01-01 | $182.65 | $127.06 | RVU14A |
| 2013-10-01 | $185.08 | $125.80 | RVU13D |
| 2013-07-01 | Rate data unavailable | Rate data unavailable | RVU13C |
| 2013-04-01 | Rate data unavailable | Rate data unavailable | RVU13B |
| 2013-01-01 | Rate data unavailable | Rate data unavailable | RVU13AR |
Where the Los Angeles, CA rate applies
Los Angeles, CA is a Medicare payment area, not a city. Our Census mapping connects it to 189 cities and communities in California. Some span more than one payment area; confirm with the service ZIP.
- Anaheim
- Long Beach
- Los Angeles
- Orange
- Acton
- Agoura Hills
- Agua Dulce
- Alhambra
42800 billing questions
How does this differ from a nasopharyngeal biopsy?
Use 42800 for a biopsy in the pharynx. Codes 42804 and 42806 describe biopsies of the nasopharynx, so the documented site determines the choice.
Can this code represent complete removal of a pharyngeal lesion?
It represents tissue sampling for diagnosis, not therapeutic removal of the lesion. When the lesion is excised, consider 42808 if its service and site criteria are met.
How are other procedures in the same session paid?
Under the standard multiple procedure reduction, Medicare pays the highest-valued procedure in full and applies a 50% reduction to the others.
Should modifier 50 be used for biopsies on both sides?
No. Bilateral adjustment is inappropriate for this code's descriptor or anatomy; do not append modifier 50.
What documentation supports reporting this biopsy?
Document the pharyngeal site, the lesion or abnormality prompting the biopsy, and the tissue sampled. Related postoperative visits during the 10-day global period are included.
Can an assistant, co-surgeon, or surgical team be billed?
Medicare does not pay an assistant at surgery for this service. Co-surgeons and team surgery are not permitted.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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