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CPT code 42800: Biopsy, pharynx tissue sampling2026 Medicare rate & RVUs in New Mexico

Reports sampling of a suspected pharyngeal lesion for tissue diagnosis, typically by an otolaryngologist during office evaluation or an operative examination.

CMS RVU26DEffective Oct 1, 2026One payment locality2.8K Medicare services in 2024

In New Mexico, Medicare pays $152.28 for 42800 in the office and $103.27 when it’s performed in a hospital or facility.

$152.28Office (non-facility)
$103.27Hospital or facility
−4.6%vs the national office rate ($159.66)

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.

We’ll open 42800 for the payment locality that covers the ZIP.

On this page 11 sections
  1. Rate in New Mexico
  2. What 42800 covers
  3. Compared with other areas
  4. Rate map
  5. How it’s calculated
  6. Payment rules
  7. Related codes
  8. Rate history
  9. Where it applies
  10. Billing questions
  11. Sources

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 New Mexico 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. New Mexico pays $152.28. The RVUs are the same everywhere; the geographic indexes change the dollars.

42800 in New Mexico vs other payment areas
  1. New Mexico · this page$152.28
  2. Los Angeles, CA · California$178.59+$26.31
  3. Washington, DC area · District of Columbia$181.82+$29.54
  4. Miami, FL · Florida$174.72+$22.44
  5. Chicago, IL · Illinois$169.60+$17.32
  6. Manhattan, NY · New York$183.91+$31.63
  7. Alaska · Alaska$186.77+$34.49

Other areas in New Mexico first, then benchmark localities. Bars start at $0.

Every other payment area

42800 in every other Medicare payment locality
Payment localityOfficeFacility
AlabamaAlabama$143.38$96.62
ArkansasArkansas$141.33$95.42
ArizonaArizona$155.36$103.58
Bakersfield, CACalifornia$167.97$109.39
Chico, CACalifornia$167.36$108.79
El Centro, CACalifornia$167.40$108.82
Fresno, CACalifornia$167.36$108.79
Hanford, CACalifornia$167.36$108.79

42800 rates by state

Office rate range in each state. Select a state to see its payment localities.

MEWIVTNHMTNDMNMINYMARIWAIDWYSDIAILINOHPANJCTORNVUTCONEMOKYWVVAMDDECAAZNMKSOKARTNNCSCDCTXLAMSALGAFLAKHI

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
42800 office rate range by state
State / territoryOffice rate rangeLocalities
AK$186.771
AL$143.381
AR$141.331
AZ$155.361
CA$167.36–$208.3429
CO$165.461
CT$170.221
DC$181.821
DE$157.911
FL$158.53–$174.723
GA$149.57–$162.902
GU$171.211
HI$171.211
IA$146.431
ID$147.491
IL$154.39–$169.604
IN$148.321
KS$146.011
KY$147.311
LA$147.19–$154.362
MA$164.59–$181.342
MD$160.82–$181.823
ME$148.53–$156.122
MI$151.35–$160.762
MN$157.791
MO$144.86–$154.593
MS$143.111
MT$159.641
NC$150.031
ND$155.491
NE$147.141
NH$163.121
NJ$171.95–$180.022
NM$152.281
NV$158.591
NY$152.28–$188.675
OH$150.501
OK$146.761
OR$157.15–$170.362
PA$150.59–$166.192
PR$160.721
RI$163.281
SC$150.561
SD$155.001
TN$146.771
TX$149.63–$165.098
UT$152.591
VA$155.79–$181.822
VI$160.721
VT$155.131
WA$164.20–$184.752
WI$150.361
WV$148.811
WY$157.831

See 42800 in every payment locality

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

Office or facility?

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 New Mexico 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

77

Locality
New Mexico
Physician work
1.000
Practice expense
0.917
Malpractice
1.201
Office calculation for 42800 in New Mexico
ComponentRVULocality factorAdjusted
Physician work1.40× 1.0001.4000
Practice expense3.17× 0.9172.9069
Malpractice0.21× 1.2010.2522
Total RVUs4.5591
Conversion factor× 33.4009

Office rate, New Mexico$152.28

Office: (1.4 × 1 + 3.17 × 0.917 + 0.21 × 1.201) × $33.4009 = $152.28

Facility: (1.4 × 1 + 1.57 × 0.917 + 0.21 × 1.201) × $33.4009 = $103.27

Open 42800 in the RVU calculator

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

RuleCMS valueWhat it means
Global period010Minor procedure: the day of the procedure plus 10 days after are included.
Multiple procedures2Standard reduction: highest-valued procedure at 100%, others at 50%.
Bilateral (modifier 50)0The 150% bilateral adjustment doesn’t apply.
Assistant at surgery (80/81/82/AS)1Not paid (statutory restriction).
Co-surgeons (62)0Not permitted.
Team surgery (66)0Not permitted.
Professional/technical0Physician service: no professional/technical split.
Split (54/55/56)0.10/0.80/0.10Share 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.

SurgeryVisit
Sep 28, 2026Oct 14, 2026

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%).

When to use modifier 51

Codes related to 42800

Related codes aren’t interchangeable: bill the code that matches the service performed.

Codes related to 42800
CodeHow it relatesOffice range, New Mexico
Used instead
42804Nasopharyngeal biopsy, nasopharynxBiopsy code for a lesion in the nasopharynx rather than the pharynx.$202.76
42806Nasopharyngeal biopsy, directly visualized tissue samplingNasopharyngeal biopsy option for a different site and operative circumstance.$227.02
42808Pharyngeal lesion treatment, excision or destructionFor excision of a pharyngeal lesion rather than diagnostic tissue sampling.$224.68

How 42800 has changed in New Mexico

42800 · Office / nonfacility

$152.28

Effective 2026-10-01

The base rate is $6.69 higher than on 2025-10-01, moving from $145.59 to $152.28 (4.6%).

It is unchanged from the immediately preceding available release, effective 2026-07-01.

Base rate by release · bars start at $0 · select a bar to compare

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

  1. January 1, 2026

    RVU26A

    $145.59changed to$152.28

    • 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
    • Practice expense GPCI 0.908 changed to 0.917
    • Malpractice GPCI 1.172 changed to 1.201

    Held through RVU26B, RVU26C, RVU26D.

  2. January 1, 2025

    RVU25A

    $151.34changed to$145.59

    • Conversion factor 33.2875 changed to 32.3465
    • Practice expense RVU 3.15 changed to 3.10

    Held through RVU25B, RVU25C, RVU25D.

  3. March 9, 2024

    RVU24AR

    $148.87changed to$151.34

    • Conversion factor 32.7442 changed to 33.2875

    Held through RVU24B, RVU24C, RVU24D.

  4. January 1, 2024

    RVU24A

    $152.70changed to$148.87

    • 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
    • Practice expense GPCI 0.902 changed to 0.908
    • Malpractice GPCI 1.169 changed to 1.172

  5. January 1, 2023

    RVU23A

    $153.72changed to$152.70

    • Conversion factor 34.6062 changed to 33.8872
    • Practice expense RVU 3.09 changed to 3.14
    • Practice expense GPCI 0.896 changed to 0.902
    • Malpractice GPCI 1.166 changed to 1.169

    Held through RVU23B, RVU23C, RVU23D.

  6. January 1, 2022

    RVU22A

    $153.74changed to$153.72

    • Conversion factor 34.8931 changed to 34.6062
    • Practice expense RVU 3.05 changed to 3.09

    Held through RVU22B, RVU22C, RVU22D.

  7. January 1, 2021

    RVU21A

    $153.97changed to$153.74

    • 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
    • Practice expense GPCI 0.908 changed to 0.896
    • Malpractice GPCI 1.207 changed to 1.166

    Held through RVU21B, RVU21C, RVU21D.

  8. January 1, 2020

    RVU20A

    $155.93changed to$153.97

    • 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
    • Practice expense GPCI 0.921 changed to 0.908
    • Malpractice GPCI 1.247 changed to 1.207

    Held through RVU20B, RVU20C, RVU20D.

  9. January 1, 2019

    RVU19A

    $155.43changed to$155.93

    • Conversion factor 35.9996 changed to 36.0391
    • Practice expense RVU 2.84 changed to 2.85

    Held through RVU19B, RVU19C, RVU19D.

  10. January 1, 2018

    RVU18AR1

    $156.50changed to$155.43

    • Conversion factor 35.8887 changed to 35.9996
    • Practice expense RVU 2.90 changed to 2.84
    • Practice expense GPCI 0.920 changed to 0.921
    • Malpractice GPCI 1.204 changed to 1.247

    Held through RVU18B, RVU18C, RVU18D.

  11. January 1, 2017

    RVU17A

    $157.68changed to$156.50

    • Conversion factor 35.8043 changed to 35.8887
    • Practice expense RVU 2.96 changed to 2.90
    • Practice expense GPCI 0.919 changed to 0.920
    • Malpractice GPCI 1.161 changed to 1.204

    Held through RVU17B, RVU17C, RVU17D.

  12. January 1, 2016

    RVU16A

    $158.01changed to$157.68

    • 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.

  13. July 1, 2015

    RVU15C

    $157.22changed to$158.01

    • Conversion factor 35.7547 changed to 35.9335

    Held through RVU15D.

  14. January 1, 2015

    RVU15A

    $156.93changed to$157.22

    • 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
    • Practice expense GPCI 0.918 changed to 0.919
    • Malpractice GPCI 1.079 changed to 1.161

    Held through RVU15B.

  15. January 1, 2014

    RVU14A

    $158.93changed to$156.93

    • 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
    • Practice expense GPCI 0.916 changed to 0.918
    • Malpractice GPCI 0.997 changed to 1.079

    Held through RVU14B, RVU14C, RVU14D.

  16. January 1, 2013

    RVU13AR

    Earliest loaded release: $158.93

    Held through RVU13B, RVU13C, RVU13D.

Rates in every CMS release
Effective fromOfficeFacilityCMS release
2026-10-01$152.28$103.27RVU26D
2026-07-01$152.28$103.27RVU26C
2026-04-01$152.28$103.27RVU26B
2026-01-01$152.28$103.27RVU26A
2025-10-01$145.59$111.23RVU25D
2025-07-01$145.59$111.23RVU25C
2025-04-01$145.59$111.23RVU25B
2025-01-01$145.59$111.23RVU25A
2024-10-01$151.34$113.55RVU24D
2024-07-01$151.34$113.55RVU24C
2024-04-01$151.34$113.55RVU24B
2024-03-09$151.34$113.55RVU24AR
2024-01-01$148.87$111.70RVU24A
2023-10-01$152.70$113.57RVU23D
2023-07-01$152.70$113.57RVU23C
2023-04-01$152.70$113.57RVU23B
2023-01-01$152.70$113.57RVU23A
2022-10-01$153.72$113.10RVU22D
2022-07-01$153.72$113.10RVU22C
2022-04-01$153.72$113.10RVU22B
2022-01-01$153.72$113.10RVU22A
2021-10-01$153.74$111.22RVU21D
2021-07-01$153.74$111.22RVU21C
2021-04-01$153.74$111.22RVU21B
2021-01-01$153.74$111.22RVU21A
2020-10-01$153.97$112.35RVU20D
2020-07-01$153.97$112.35RVU20C
2020-04-01$153.97$112.35RVU20B
2020-01-01$153.97$112.35RVU20A
2019-10-01$155.93$113.78RVU19D
2019-07-01$155.93$113.78RVU19C
2019-04-01$155.93$113.78RVU19B
2019-01-01$155.93$113.78RVU19A
2018-10-01$155.43$112.33RVU18D
2018-07-01$155.43$112.33RVU18C
2018-04-01$155.43$112.33RVU18B
2018-01-01$155.43$112.33RVU18AR1
2017-10-01$156.50$112.92RVU17D
2017-07-01$156.50$112.92RVU17C
2017-04-01$156.50$112.92RVU17B
2017-01-01$156.50$112.92RVU17A
2016-10-01$157.68$113.26RVU16D
2016-07-01$157.68$113.26RVU16C
2016-04-01$157.68$113.26RVU16B
2016-01-01$157.68$113.26RVU16A
2015-10-01$158.01$113.76RVU15D
2015-07-01$158.01$113.76RVU15C
2015-04-01$157.22$113.19RVU15B
2015-01-01$157.22$113.19RVU15A
2014-10-01$156.93$112.86RVU14D
2014-07-01$156.93$112.86RVU14C
2014-04-01$156.93$112.86RVU14B
2014-01-01$156.93$112.86RVU14A
2013-10-01$158.93$111.87RVU13D
2013-07-01$158.93$111.87RVU13C
2013-04-01$158.93$111.87RVU13B
2013-01-01$158.93$111.87RVU13AR

Price 42800 for an earlier date of service

Where the New Mexico rate applies

New Mexico is a Medicare payment area, not a city. Our Census mapping connects it to 528 cities and communities in New Mexico. Some span more than one payment area; confirm with the service ZIP.

  • Abeytas
  • Abiquiu
  • Acomita Lake
  • Adelino
  • Agua Fria
  • Alamillo
  • Alamo
  • Alamogordo

Browse all communities in New Mexico

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
RVUs for 42800PPRRVU2026_Oct_nonQPP.csv, line 5,071 (RVU26D)
Geographic factors for New MexicoGPCI2026.csv, line 77 (RVU26D)

Open CMS sourceHow we calculate rates

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