$171.21
Choose 42804 for a nasopharyngeal specimen. Choose 42800 when the biopsy site is the oropharynx.
On this page
CMS RVU26D · Effective 2026-10-01
42804 Nasopharyngeal biopsy Medicare reimbursement rates in Hawaii
Biopsy of a lesion or abnormal tissue in the nasopharynx, reported when the clinician obtains tissue for diagnostic evaluation. Compare 42804 office and facility rates across CMS payment localities in Hawaii.
Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.
What does Medicare pay for 42804 in Hawaii?
Hawaii has 1 payment locality in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the payment area shown below, using the same CMS release.
Office / nonfacility
$235.83
1 of 1 localities have a supported rate.
Payment area: Hawaii, Guam
One mapped payment locality.
Facility setting
$119.24
1 of 1 localities have a supported rate.
Payment area: Hawaii, Guam
One mapped payment locality.
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
Otolaryngology
About 42804: Nasopharyngeal lesion biopsy
Biopsy of a lesion or abnormal tissue in the nasopharynx, reported when the clinician obtains tissue for diagnostic evaluation.
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.
CMS billing rules for 42804
- Global period
- Minor procedure with a 10-day global period: related postoperative visits for 10 days are included.
- Multiple procedures
- Standard multiple procedure reduction: the highest-valued procedure is paid in full and others at 50% when performed in the same session.
- Bilateral procedures
- Bilateral adjustment does not apply; the descriptor or anatomy makes modifier 50 inappropriate.
- Assistant at surgery
- Statutory restriction: assistant at surgery is not paid.
- Co-surgeons
- Co-surgeons not permitted.
- Team surgery
- Team surgery not permitted.
Where the value comes from
- Work RVU1.26 · 20%
- Practice expense (office) RVU5.01 · 78%
- Malpractice RVU0.18 · 3%
364
Medicare services in 2024 · #3814 by national volume
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.
42804 compared with similar codes
Office rates for Hawaii, from the same CMS release.
$262.06
This is a closely related nasopharyngeal biopsy code. Distinguish it from 42804 using the documented procedure and approach, not merely the site.
$249.60
Use 42804 when tissue is sampled for diagnostic evaluation; 42808 describes excision of a pharyngeal lesion.
Compare 42804 by payment locality
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
1 of 1 payment localities
Hawaii, Guam →
Office / nonfacility
$235.83
Facility
$119.24
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How this local rate is calculated
Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 42804 in Hawaii, Guam.
PPRRVU2026_Oct_nonQPP.csv
5,072
- Code
- 42804
- Physician work
- 1.26
- Practice expense
- 5.01
- Malpractice
- 0.18
GPCI2026.csv
46
- Locality
- Hawaii, Guam
- Physician work
- 1.000
- Practice expense
- 1.137
- Malpractice
- 0.579
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 1.26 | × 1.000 | 1.2600 |
| Practice expense | 5.01 | × 1.137 | 5.6964 |
| Malpractice | 0.18 | × 0.579 | 0.1042 |
| Total RVUs | 7.0606 | ||
| Conversion factor | × 33.4009 | ||
Office / nonfacility rate, Hawaii, Guam$235.83
Explore RVUs, geographic factors and the full formula
Office / nonfacility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 1.26 | 1 |
| Practice expense | 5.01 | 1.137 |
| Malpractice | 0.18 | 0.579 |
(1.26 × 1 + 5.01 × 1.137 + 0.18 × 0.579) × $33.4009 = $235.83
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 1.26 | 1 |
| Practice expense | 1.94 | 1.137 |
| Malpractice | 0.18 | 0.579 |
(1.26 × 1 + 1.94 × 1.137 + 0.18 × 0.579) × $33.4009 = $119.24
The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.
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 indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.
Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.
5,0694276F,,Potent antivir thxpy rxd,I,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00
5,0704279F,,Pcp prophylaxis rxd,I,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00
5,07142800,,Biopsy of throat,A,,1.40,3.17,,1.57,,0.21,4.78,3.18,0,010,0.10,0.80,0.10,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,07242804,,Biopsy of upper nose/throat,A,,1.26,5.01,,1.94,,0.18,6.45,3.38,0,010,0.10,0.80,0.10,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,07342806,,Biopsy of upper nose/throat,A,,1.59,5.39,,2.04,,0.22,7.20,3.85,0,010,0.10,0.80,0.10,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,07442808,,Excise pharynx lesion,A,,2.29,4.38,,1.80,,0.35,7.02,4.44,0,010,0.10,0.80,0.10,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,07542809,,Remove pharynx foreign body,A,,1.81,4.33,,1.41,,0.28,6.42,3.50,0,010,0.10,0.80,0.10,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
4309102,FL,99,REST OF FLORIDA,1.000,0.956,1.503
4410212,GA,01,ATLANTA,1.003,1.016,1.201
4510212,GA,99,REST OF GEORGIA,1.000,0.892,1.192
4601212,HI,01,"HAWAII, GUAM",1.000,1.137,0.579
4702202,ID,00,IDAHO,1.000,0.920,0.473
4806102,IL,16,CHICAGO,1.007,1.005,2.295
4906102,IL,12,EAST ST. LOUIS,1.000,0.920,2.014