Billing code 42975: Sleep endoscopyMedicare rate & RVUs in Georgia
Flexible endoscopy during medication-induced sleep shows patterns of upper-airway collapse in patients being evaluated for obstructive sleep apnea treatment.
CMS doesn’t publish an office rate for 42975 in Georgia.
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 42975 covers
An otolaryngologist passes a flexible endoscope through the nose while medication-induced sleep allows assessment of how the upper airway behaves in a sleep-like state. The examination can show collapse involving structures such as the soft palate, pharyngeal walls, tongue base, or epiglottis. It is used in evaluating obstructive sleep apnea, including when airway surgery or hypoglossal nerve stimulation is being considered and the pattern of obstruction may guide treatment planning.
Report 42975 for the medication-induced, flexible endoscopic airway evaluation—not an awake office examination alone. Documentation should support the sleep-like state, the endoscopic findings, and the clinical reason for evaluating airway collapse. CMS assigns a 0-day global period, so same-day preoperative and postoperative care is included. When related endoscopies are performed together, endoscopy family pricing applies. Modifier 50 is inappropriate. Medicare does not pay an assistant at surgery for this service, 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 42975 pays more and less in Georgia
| Payment locality | Office | Facility |
|---|---|---|
| Atlanta | Unavailable | $85.47 |
| Rest Of Georgia | Unavailable | $82.14 |
How the 42975 rate is calculated
Each of 42975’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 · 42975
RVUs × geographic indexes × conversion factor
Work1.54
1.54 RVUs× 1.000 GPCI
Practice expense0.75
0.75 RVUs× 1.000 GPCI
Malpractice0.21
0.21 RVUs× 1.000 GPCI
Adjusted RVUs
2.5000
Conversion factor
$33.4009
Medicare rate
$83.50
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 42975
The CMS indicators that decide how 42975 is paid alongside other services.
CMS payment indicators · 42975
Sleep endoscopy
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 000 | Same-day global: pre- and post-op care on the day of the procedure is included. |
| Multiple procedures | 3 | Endoscopy family rules apply. |
| 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. |
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
42975 without 51 · national facility
$83.50
Sleep endoscopy
42975-51 · Second procedure: 50%
$41.75
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%).
42975 compared with similar codes
Compare codes · National
4 codes, side by side
How to choose
- 31575Laryngoscopy
- Choose 42975 when flexible endoscopy is performed during medication-induced sleep to assess airway collapse. Code 31575 describes an awake flexible laryngeal examination.
- 31525Laryngoscopy
- Code 31525 is diagnostic direct laryngoscopy. It does not represent flexible endoscopic evaluation of the airway during medication-induced sleep.
- 95810Sleep study
- Polysomnography records sleep and respiratory data to evaluate sleep-disordered breathing; 42975 visualizes the airway during induced sleep to assess collapse patterns.
42975 billing questions
How is 42975 different from an awake flexible laryngoscopy?
42975 evaluates airway behavior during medication-induced sleep. An awake flexible laryngoscopy examines the airway while the patient is awake and does not show the same sleep-related collapse pattern.
Can an awake laryngoscopy be separately reported at the same encounter?
Do not report an additional scope service solely for the flexible endoscopic examination inherent in 42975. If another endoscopic service is performed, CMS endoscopy family pricing applies when the procedures are related and performed together.
Should modifier 50 be appended for both sides of the airway?
No. CMS identifies bilateral adjustment as inappropriate for this code; the descriptor or anatomy does not support modifier 50.
Is an assistant surgeon payable?
No. CMS lists a statutory restriction on assistant-at-surgery payment for 42975; co-surgeons and team surgery are also not permitted.
What documentation supports reporting 42975?
Document the clinical reason for assessing sleep-related airway obstruction, the medication-induced sleep-like state, the flexible endoscopic examination, and the observed airway findings.
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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