Billing code 42806: Nasopharyngeal biopsyMedicare rate & RVUs in Delaware
ENT clinicians use this code to obtain tissue from a nasopharyngeal abnormality under direct visualization when surgical biopsy, rather than brush or wash sampling, is performed.
Medicare pays $237.85 for 42806 in the office in Delaware (Delaware). 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.
On this page 9 sections
What 42806 covers
An otolaryngologist uses directly visualized surgical instruments to obtain tissue from an abnormal area in the nasopharynx, the space behind the nasal cavity and above the soft palate. Typical indications include a visible mass, irregular mucosa, or other suspicious finding requiring tissue diagnosis. The procedure may be performed in an operating room or another setting where the clinician can directly visualize and sample the target.
Choose this code for a nasopharyngeal tissue biopsy performed under direct visualization; brush or washing-based sampling is represented by a different code. The operative note should identify the nasopharyngeal target, the direct-visualization approach, and the tissue sampling performed. Medicare includes related postoperative visits for 10 days in the procedure’s 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. Medicare does not pay an assistant at surgery for this service, and co-surgeon and team-surgery billing 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.
42806 in Delaware
| Payment locality | Office | Facility |
|---|---|---|
| Delaware | $237.85 | $127.30 |
How the 42806 rate is calculated
Each of 42806’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 · 42806
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 1.59Practice expense 5.39Malpractice 0.22
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 42806
42806 has a 10-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42806
Nasopharyngeal biopsy
| 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 · 42806
Nasopharyngeal biopsy
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
42806 without 51 · national office
$240.49
Nasopharyngeal biopsy
42806-51 · Second procedure: 50%
$120.25
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%).
42806 compared with similar codes
Compare codes
42806 vs 42804 vs 42800 vs 42808: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 42804Nasopharyngeal biopsy
- 42804 describes brush or washing collection from the nasopharynx. This code is for a tissue biopsy performed under direct visualization.
- 42800Biopsy
- 42800 applies to a pharyngeal biopsy. Use this code when the sampled site is in the nasopharynx.
- 42808Pharyngeal lesion treatment
- 42808 describes excision of a pharyngeal lesion. This code is for biopsy sampling of a nasopharyngeal abnormality.
42806 billing questions
How do I distinguish this code from 42804?
Use this code for a directly visualized surgical tissue biopsy of the nasopharynx. Code 42804 describes nasopharyngeal sampling by brush or washings.
When is 42800 a better choice?
Code 42800 is for biopsy of the pharynx. Choose this code when the sampled target is in the nasopharynx and the biopsy is performed under direct visualization.
Does excising a lesion support this biopsy code?
A tissue sample taken for diagnosis supports a biopsy. When the procedure removes a pharyngeal lesion rather than sampling it, compare the documentation with code 42808.
What documentation supports reporting this service?
Document the nasopharyngeal site, the abnormality sampled, direct visualization, and the tissue biopsy performed. The note should distinguish tissue sampling from brush or washing collection.
Are postoperative visits included?
Related postoperative visits during the 10-day global period are included in the procedure.
Can modifier 50 be used for bilateral sampling?
No. CMS identifies bilateral adjustment as inappropriate for this service.
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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