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CPT code 42804: Nasopharyngeal biopsy, nasopharynx2026 Medicare rate & RVUs in New Mexico

Biopsy of a lesion or abnormal tissue in the nasopharynx, reported when the clinician obtains tissue for diagnostic evaluation.

CMS RVU26DEffective Oct 1, 2026One payment locality364 Medicare services in 2024

In New Mexico, Medicare pays $202.76 for 42804 in the office and $108.73 when it’s performed in a hospital or facility.

$202.76Office (non-facility)
$108.73Hospital or facility
−5.9%vs the national office rate ($215.44)

Check a contract rate as a % of Medicare · 42804 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 42804 for the payment locality that covers the ZIP.

On this page 11 sections
  1. Rate in New Mexico
  2. What 42804 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 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.

How New Mexico compares for 42804

Across 109 of 109 payment localities, the office rate for 42804 runs from $188.93 in Arkansas to $291.24 in San Benito County, CA. New Mexico pays $202.76. The RVUs are the same everywhere; the geographic indexes change the dollars.

42804 in New Mexico vs other payment areas
  1. New Mexico · this page$202.76
  2. Los Angeles, CA · California$245.76+$43.00
  3. Washington, DC area · District of Columbia$248.17+$45.41
  4. Miami, FL · Florida$231.49+$28.73
  5. Chicago, IL · Illinois$224.35+$21.59
  6. Manhattan, NY · New York$248.76+$46.00
  7. Alaska · Alaska$244.66+$41.90

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

Every other payment area

42804 in every other Medicare payment locality
Payment localityOfficeFacility
AlabamaAlabama$191.91$102.19
ArkansasArkansas$188.93$100.84
ArizonaArizona$209.38$110.02
Bakersfield, CACalifornia$229.95$117.56
Chico, CACalifornia$229.43$117.04
El Centro, CACalifornia$229.46$117.07
Fresno, CACalifornia$229.43$117.04
Hanford, CACalifornia$229.43$117.04

42804 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.

$188.93

$260.34

Color shows the midpoint of each state’s locality range.

View every state and territory as a table
42804 office rate range by state
State / territoryOffice rate rangeLocalities
AK$244.661
AL$191.911
AR$188.931
AZ$209.381
CA$229.43–$291.2429
CO$225.331
CT$230.431
DC$248.171
DE$213.031
FL$211.10–$231.493
GA$198.52–$219.452
GU$235.831
HI$235.831
IA$197.591
ID$198.881
IL$204.26–$224.894
IN$200.131
KS$196.391
KY$196.351
LA$195.94–$206.382
MA$223.76–$248.962
MD$217.37–$248.173
ME$199.78–$211.712
MI$201.65–$213.702
MN$216.061
MO$192.19–$207.423
MS$190.611
MT$215.421
NC$202.051
ND$211.861
NE$198.811
NH$221.551
NJ$233.10–$245.272
NM$202.761
NV$214.601
NY$205.28–$254.915
OH$200.931
OK$196.191
OR$212.98–$233.142
PA$201.38–$224.212
PR$217.191
RI$221.111
SC$201.821
SD$211.441
TN$197.421
TX$199.95–$224.548
UT$204.781
VA$210.82–$248.172
VI$217.191
VT$210.791
WA$223.41–$254.432
WI$204.251
WV$196.111
WY$213.871

See 42804 in every payment locality

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

Office or facility?

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.

The exact New Mexico inputs and CMS source lines

PPRRVU2026_Oct_nonQPP.csv

5,072

Code
42804
Physician work
1.26
Practice expense
5.01
Malpractice
0.18

GPCI2026.csv

77

Locality
New Mexico
Physician work
1.000
Practice expense
0.917
Malpractice
1.201
Office calculation for 42804 in New Mexico
ComponentRVULocality factorAdjusted
Physician work1.26× 1.0001.2600
Practice expense5.01× 0.9174.5942
Malpractice0.18× 1.2010.2162
Total RVUs6.0703
Conversion factor× 33.4009

Office rate, New Mexico$202.76

Office: (1.26 × 1 + 5.01 × 0.917 + 0.18 × 1.201) × $33.4009 = $202.76

Facility: (1.26 × 1 + 1.94 × 0.917 + 0.18 × 1.201) × $33.4009 = $108.73

Open 42804 in the RVU calculator

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

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 · 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.

SurgeryVisit
Sep 28, 2026Oct 14, 2026

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%).

When to use modifier 51

Codes related to 42804

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

Codes related to 42804
CodeHow it relatesOffice range, New Mexico
Same family
42800Biopsy, pharynx tissue samplingBiopsy code for the oropharynx rather than the nasopharynx.$152.28
42806Nasopharyngeal biopsy, directly visualized tissue samplingRelated nasopharyngeal biopsy code; distinguish by the documented service and approach.$227.02
Used instead
42808Pharyngeal lesion treatment, excision or destructionPharyngeal lesion excision when the service removes the lesion rather than sampling it for biopsy.$224.68

How 42804 has changed in New Mexico

42804 · Office / nonfacility

$202.76

Effective 2026-10-01

The base rate is $8.53 higher than on 2025-10-01, moving from $194.23 to $202.76 (4.4%).

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

    $194.23changed to$202.76

    • Conversion factor 32.3465 changed to 33.4009
    • Work RVU 1.29 changed to 1.26
    • Practice expense RVU 4.96 changed to 5.01
    • 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

    $202.99changed to$194.23

    • Conversion factor 33.2875 changed to 32.3465
    • Practice expense RVU 5.05 changed to 4.96
    • Malpractice RVU 0.19 changed to 0.18

    Held through RVU25B, RVU25C, RVU25D.

  3. March 9, 2024

    RVU24AR

    $199.68changed to$202.99

    • Conversion factor 32.7442 changed to 33.2875

    Held through RVU24B, RVU24C, RVU24D.

  4. January 1, 2024

    RVU24A

    $205.60changed to$199.68

    • Conversion factor 33.8872 changed to 32.7442
    • Practice expense GPCI 0.902 changed to 0.908
    • Malpractice GPCI 1.169 changed to 1.172

  5. January 1, 2023

    RVU23A

    $207.44changed to$205.60

    • Conversion factor 34.6062 changed to 33.8872
    • Practice expense RVU 4.99 changed to 5.05
    • Malpractice RVU 0.20 changed to 0.19
    • 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

    $199.18changed to$207.44

    • Conversion factor 34.8931 changed to 34.6062
    • Practice expense RVU 4.71 changed to 4.99
    • Malpractice RVU 0.17 changed to 0.20

    Held through RVU22B, RVU22C, RVU22D.

  7. January 1, 2021

    RVU21A

    $191.37changed to$199.18

    • Conversion factor 36.0896 changed to 34.8931
    • Practice expense RVU 4.18 changed to 4.71
    • Malpractice RVU 0.18 changed to 0.17
    • 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

    $193.44changed to$191.37

    • Conversion factor 36.0391 changed to 36.0896
    • Practice expense RVU 4.17 changed to 4.18
    • Malpractice RVU 0.19 changed to 0.18
    • 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

    $188.92changed to$193.44

    • Conversion factor 35.9996 changed to 36.0391
    • Practice expense RVU 4.04 changed to 4.17

    Held through RVU19B, RVU19C, RVU19D.

  10. January 1, 2018

    RVU18AR1

    $190.54changed to$188.92

    • Conversion factor 35.8887 changed to 35.9996
    • Practice expense RVU 4.12 changed to 4.04
    • 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

    $192.28changed to$190.54

    • Conversion factor 35.8043 changed to 35.8887
    • Practice expense RVU 4.20 changed to 4.12
    • 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

    $191.66changed to$192.28

    • Conversion factor 35.9335 changed to 35.8043
    • Practice expense RVU 4.16 changed to 4.20

    Held through RVU16B, RVU16C, RVU16D.

  13. July 1, 2015

    RVU15C

    $190.70changed to$191.66

    • Conversion factor 35.7547 changed to 35.9335

    Held through RVU15D.

  14. January 1, 2015

    RVU15A

    $190.79changed to$190.70

    • Conversion factor 35.8228 changed to 35.7547
    • Practice expense RVU 4.22 changed to 4.16
    • Malpractice RVU 0.15 changed to 0.19
    • 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

    $196.10changed to$190.79

    • Conversion factor 34.0230 changed to 35.8228
    • Practice expense RVU 4.71 changed to 4.22
    • Malpractice RVU 0.16 changed to 0.15
    • 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: $196.10

    Held through RVU13B, RVU13C, RVU13D.

Rates in every CMS release
Effective fromOfficeFacilityCMS release
2026-10-01$202.76$108.73RVU26D
2026-07-01$202.76$108.73RVU26C
2026-04-01$202.76$108.73RVU26B
2026-01-01$202.76$108.73RVU26A
2025-10-01$194.23$114.93RVU25D
2025-07-01$194.23$114.93RVU25C
2025-04-01$194.23$114.93RVU25B
2025-01-01$194.23$114.93RVU25A
2024-10-01$202.99$118.66RVU24D
2024-07-01$202.99$118.66RVU24C
2024-04-01$202.99$118.66RVU24B
2024-03-09$202.99$118.66RVU24AR
2024-01-01$199.68$116.73RVU24A
2023-10-01$205.60$119.10RVU23D
2023-07-01$205.60$119.10RVU23C
2023-04-01$205.60$119.10RVU23B
2023-01-01$205.60$119.10RVU23A
2022-10-01$207.44$119.07RVU22D
2022-07-01$207.44$119.07RVU22C
2022-04-01$207.44$119.07RVU22B
2022-01-01$207.44$119.07RVU22A
2021-10-01$199.18$113.83RVU21D
2021-07-01$199.18$113.83RVU21C
2021-04-01$199.18$113.83RVU21B
2021-01-01$199.18$113.83RVU21A
2020-10-01$191.37$113.38RVU20D
2020-07-01$191.37$113.38RVU20C
2020-04-01$191.37$113.38RVU20B
2020-01-01$191.37$113.38RVU20A
2019-10-01$193.44$114.77RVU19D
2019-07-01$193.44$114.77RVU19C
2019-04-01$193.44$114.77RVU19B
2019-01-01$193.44$114.77RVU19A
2018-10-01$188.92$112.66RVU18D
2018-07-01$188.92$112.66RVU18C
2018-04-01$188.92$112.66RVU18B
2018-01-01$188.92$112.66RVU18AR1
2017-10-01$190.54$113.28RVU17D
2017-07-01$190.54$113.28RVU17C
2017-04-01$190.54$113.28RVU17B
2017-01-01$190.54$113.28RVU17A
2016-10-01$192.28$113.97RVU16D
2016-07-01$192.28$113.97RVU16C
2016-04-01$192.28$113.97RVU16B
2016-01-01$192.28$113.97RVU16A
2015-10-01$191.66$114.05RVU15D
2015-07-01$191.66$114.05RVU15C
2015-04-01$190.70$113.48RVU15B
2015-01-01$190.70$113.48RVU15A
2014-10-01$190.79$112.52RVU14D
2014-07-01$190.79$112.52RVU14C
2014-04-01$190.79$112.52RVU14B
2014-01-01$190.79$112.52RVU14A
2013-10-01$196.10$112.58RVU13D
2013-07-01$196.10$112.58RVU13C
2013-04-01$196.10$112.58RVU13B
2013-01-01$196.10$112.58RVU13AR

Price 42804 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

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

Show the CMS file lines behind this rate
RVUs for 42804PPRRVU2026_Oct_nonQPP.csv, line 5,072 (RVU26D)
Geographic factors for New MexicoGPCI2026.csv, line 77 (RVU26D)

Open CMS sourceHow we calculate rates

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