CPT code 42804: Nasopharyngeal biopsy, nasopharynx2026 Medicare rate & RVUs in Maryland
Biopsy of a lesion or abnormal tissue in the nasopharynx, reported when the clinician obtains tissue for diagnostic evaluation.
Medicare pays $217.37–$248.17 for 42804 in the office in Maryland, from Rest of Maryland to Washington, DC area. Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
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On this page 9 sections
What 42804 covers
An otolaryngologist typically performs this service to obtain tissue from an abnormal area in the nasopharynx, the upper part of the throat behind the nasal cavity. The clinician reaches the site through the nose or another documented route and removes a specimen for diagnostic evaluation. The procedure may occur in an office or facility, depending on the lesion’s location, access, and the patient’s needs.
Report the code when the service is a nasopharyngeal biopsy, rather than a biopsy of the oropharynx or removal of a lesion. The record should identify the sampled site, describe the lesion or abnormal tissue, and document the biopsy performed. Related postoperative visits during the 10-day global period are included. When multiple procedures are performed in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard reduction. Modifier 50 is inappropriate. Assistant-at-surgery payment is restricted, and 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.
Where 42804 pays more and less in Maryland
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
3 payment localities
$217.37 to $248.17
| Payment locality | Office | Facility |
|---|---|---|
| Baltimore area, MD | $229.75 | $119.72 |
| Rest of Maryland | $217.37 | $113.60 |
| Washington, DC area | $248.17 | $127.38 |
How the 42804 rate is calculated
Each of 42804’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 · 42804
RVUs × geographic indexes × conversion factor
Work1.26
1.26 RVUs× 1.000 GPCI
Practice expense5.01
5.01 RVUs× 1.000 GPCI
Malpractice0.18
0.18 RVUs× 1.000 GPCI
Adjusted RVUs
6.4500
Conversion factor
$33.4009
Medicare rate
$215.44
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 42804
42804 has a 10-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42804
Nasopharyngeal biopsy, nasopharynx
| 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 · 42804
Nasopharyngeal biopsy, nasopharynx
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
42804 without 51 · national office
$215.44
Nasopharyngeal biopsy, nasopharynx
42804-51 · Second procedure: 50%
$107.72
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%).
42804 compared with similar codes
Compare codes · National
4 codes, side by side
How to choose
- 42800BiopsyPharynx tissue sampling
- Choose 42804 for a nasopharyngeal specimen. Choose 42800 when the biopsy site is the oropharynx.
- 42806Nasopharyngeal biopsyDirectly visualized tissue sampling
- This is a closely related nasopharyngeal biopsy code. Distinguish it from 42804 using the documented procedure and approach, not merely the site.
- 42808Pharyngeal lesion treatmentExcision or destruction
- Use 42804 when tissue is sampled for diagnostic evaluation; 42808 describes excision of a pharyngeal lesion.
42804 billing questions
How does this differ from code 42800?
Code 42804 is for tissue sampled from the nasopharynx. Code 42800 is used when the sampled site is the oropharynx.
How does this differ from code 42806?
Both codes concern nasopharyngeal biopsy. Use the code that matches the documented biopsy service and approach; do not select between them based only on the diagnosis or specimen.
Can a biopsy and lesion excision be reported as the same service?
No. Code 42804 represents obtaining a biopsy specimen; code 42808 describes excision of a pharyngeal lesion. The operative documentation should show which service was performed.
Should modifier 50 be appended for bilateral sampling?
No. The CMS bilateral adjustment does not apply to this code, and modifier 50 is inappropriate.
How does the multiple procedure reduction affect payment?
When multiple procedures are performed in the same session, the highest-valued procedure is paid in full and the others are subject to the standard 50% reduction.
Are related postoperative visits included?
Yes. Related postoperative visits during the 10-day global period are included in the procedure.
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
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