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Billing code 42826: TonsillectomyMedicare rate & RVUs

Removal of the palatine tonsils in a patient age 12 or older for tonsillar disease or obstruction when a combined tonsil-and-adenoid code is not appropriate.

CMS RVU26DEffective Oct 1, 2026109 payment localities1.6K Medicare services in 2024

Medicare pays $231.47 for 42826 nationally in a facility.

Medicare rate · 42826

Tonsillectomy

Swap in your local Medicare rate.

Work RVUs
3.36
Total RVUs
6.93
Global days
090

National rate · 2026

$231.47

Facility setting, before claim adjustments.

See every locality for 42826 → · Billed by an NP, PA or therapist? →

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 10 sections
  1. Medicare rate
  2. What 42826 covers
  3. By payment locality
  4. Rate map
  5. How it’s calculated
  6. Payment rules
  7. Similar codes
  8. Related codes
  9. Billing questions
  10. Sources

What 42826 covers

This code describes surgical removal of the palatine tonsils in a patient who is at least 12 on the date of surgery. Otolaryngologists commonly perform the procedure in a hospital or ambulatory surgery center, often for recurrent tonsillar infections or obstructive tonsillar enlargement. It covers tonsil removal without the adenoidectomy included in a combined tonsil-and-adenoid procedure.

Choose the age-specific code based on the patient’s age on the service date; use the under-12 tonsillectomy code for younger patients. The operative report should support removal of the palatine tonsils and document the indication and any concurrent adenoid procedure. Medicare includes the day-before preoperative visit and 90 days of related postoperative care in the major-surgery global period. 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 50% multiple-procedure reduction. Modifier 50 is inappropriate. Medicare does not pay an assistant at surgery; 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 42826 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

42826 office and facility rates by payment locality
Payment localityOfficeFacility
AlabamaUnavailable$211.61
Alaska*Unavailable$287.09
ArizonaUnavailable$225.96
ArkansasUnavailable$209.14
AtlantaUnavailable$236.68
AustinUnavailable$235.85
BakersfieldUnavailable$237.24
Baltimore/Surr. CntysUnavailable$244.60
BeaumontUnavailable$221.04
BrazoriaUnavailable$227.91

42826 rates by state

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

MEWIVTNHMTNDMNMINYMARIWAIDWYSDIAILINOHPANJCTORNVUTCONEMOKYWVVAMDDECAAZNMKSOKARTNNCSCDCTXLAMSALGAFLAKHI

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Local rates. Clear comparisons.

Hover or focus a tile to see its rate range. Select it to open the state’s fee schedule.

View every state and territory as a table
42826 office rate range by state
State / territoryOffice rate rangeLocalities
AKNo published base rate1
ALNo published base rate1
ARNo published base rate1
AZNo published base rate1
CANo published base rate29
CONo published base rate1
CTNo published base rate1
DCNo published base rate1
DENo published base rate1
FLNo published base rate3
GANo published base rate2
GUNo published base rate1
HINo published base rate1
IANo published base rate1
IDNo published base rate1
ILNo published base rate4
INNo published base rate1
KSNo published base rate1
KYNo published base rate1
LANo published base rate2
MANo published base rate2
MDNo published base rate3
MENo published base rate2
MINo published base rate2
MNNo published base rate1
MONo published base rate3
MSNo published base rate1
MTNo published base rate1
NCNo published base rate1
NDNo published base rate1
NENo published base rate1
NHNo published base rate1
NJNo published base rate2
NMNo published base rate1
NVNo published base rate1
NYNo published base rate5
OHNo published base rate1
OKNo published base rate1
ORNo published base rate2
PANo published base rate2
PRNo published base rate1
RINo published base rate1
SCNo published base rate1
SDNo published base rate1
TNNo published base rate1
TXNo published base rate8
UTNo published base rate1
VANo published base rate2
VINo published base rate1
VTNo published base rate1
WANo published base rate2
WINo published base rate1
WVNo published base rate1
WYNo published base rate1

How the 42826 rate is calculated

Each of 42826’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 · 42826

RVUs × geographic indexes × conversion factor

Swap in your local Medicare rate.

Work 3.36Practice expense 3.09Malpractice 0.48

6.9300 adjusted RVUs×$33.4009 conversion factor=$231.47

All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.

Payment rules and modifiers for 42826

42826 has a 90-day global period: related visits in that window are included in the surgery payment.

CMS payment indicators · 42826

Tonsillectomy

RuleCMS valueWhat it means
Global period090Major surgery: the day before, the day of, and 90 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)0.09/0.81/0.10Share of the payment for pre-op, the procedure itself, and post-op care.

Global surgery period · 42826

Tonsillectomy

90-day global period ends

Dec 30, 2026

Covers Sep 30, 2026 through Dec 30, 2026 (92 days, including the day before surgery).

Visit on Oct 31, 2026

Day 30 of the 90-day post-op period: related follow-up care is included in the surgical payment.

  • 24 Unrelated E/M visit by the same physician
  • 79 Unrelated procedure (starts its own global period)
  • 58 Staged, more extensive, or therapy procedure that was planned
  • 78 Unplanned return to the operating room for a related complication
SurgeryVisit
Sep 23, 2026Jan 10, 2027

Pre-op dayGlobal period

What modifiers do to the payment

Modifier 51 · payment effect

With and without the modifier

42826 without 51 · national facility

$231.47

Tonsillectomy

42826-51 · Second procedure: 50%

$115.74

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

42826 compared with similar codes

Compare codes

42826 vs 42825 vs 42821 vs 42870: national Medicare rates

Swap in your local Medicare rate.

  • 42826
    Tonsillectomy · 3.36 wRVU
    —
  • 42825
    Tonsillectomy · 3.42 wRVU
    —
  • 42821
    Tonsil and adenoid removal · 4.25 wRVU
    —
  • 42870
    Tonsil excision · 5.38 wRVU
    —

How to choose

42825Tonsillectomy
Both codes describe tonsil removal; select 42826 for patients age 12 or older and 42825 for patients younger than 12.
42821Tonsil and adenoid removal
42821 is the combined procedure when both tonsils and adenoids are removed in a patient age 12 or older; 42826 covers tonsil removal alone.
42870Tonsil excision
42870 addresses excision of lingual tonsil tissue at the base of the tongue, not removal of the palatine tonsils.

Codes related to 42826

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

Codes related to 42826
CodeHow it relatesNational office range
Same family
42825TonsillectomyAge-specific tonsillectomy code for patients younger than 12.No office rate
Used instead
42820Tonsil and adenoid removalCombined tonsil and adenoid removal for patients younger than 12.No office rate
42821Tonsil and adenoid removalCombined tonsil and adenoid removal for patients age 12 or older.No office rate

42826 billing questions

How does this code differ from 42825?

42826 is for tonsil removal when the patient is age 12 or older on the date of surgery. 42825 is the age-specific code for patients younger than 12.

Should modifier 50 be appended for removal of both tonsils?

No. The code represents the tonsillectomy, and CMS identifies bilateral adjustment as inappropriate.

Which code applies when the adenoids are removed too?

Use the age-appropriate combined tonsil-and-adenoid code when both are removed: 42821 for a patient age 12 or older, or 42820 for a younger patient.

Does the global period include postoperative visits?

Yes. The 90-day major-surgery global period includes the day-before preoperative visit and related postoperative care during the 90 days after surgery.

Can an assistant surgeon or co-surgeon be paid for this procedure?

Medicare does not pay an assistant at surgery for this code. Co-surgeons and team surgery are not permitted.

What happens if another procedure is performed in the same session?

The highest-valued procedure is paid in full, and other procedures are subject to the standard multiple-procedure reduction when performed in the same session.

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 42826PPRRVU2026_Oct_nonQPP.csv, line 5,082 (RVU26D)

Open CMS sourceHow we calculate rates

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