No office rate
Use 42821 for combined tonsil and adenoid removal when the patient is age 12 or older; 42820 is for patients younger than 12.
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CMS RVU26D · Effective 2026-10-01
42820 Tonsil and adenoid removal Medicare reimbursement rates in Idaho
Reports removal of both palatine tonsils and adenoid tissue in one operation for a patient younger than 12, including infection or airway obstruction cases. Compare 42820 office and facility rates across CMS payment localities in Idaho.
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 42820 in Idaho?
Idaho 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
No supported rate
Facility setting
$242.17
1 of 1 localities have a supported rate.
Payment area: Idaho
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 surgery
About 42820: Tonsillectomy and adenoidectomy under age 12
Reports removal of both palatine tonsils and adenoid tissue in one operation for a patient younger than 12, including infection or airway obstruction cases.
The operation removes the palatine tonsils and adenoid tissue during the same session. Otolaryngologists commonly perform it for recurrent tonsillitis or sleep-disordered breathing associated with enlarged adenotonsillar tissue. The procedure is generally performed in a hospital or ambulatory surgery center, often under general anesthesia.
Select this code when the patient is younger than 12 on the date of surgery and both tonsils and adenoids are removed. The operative report should identify both tissues removed, the clinical indication, and the service date. Tonsillectomy alone or adenoidectomy alone is reported with the code for that procedure instead. This major surgery has a 90-day global period that includes the day-before preoperative visit and related postoperative care. For multiple procedures in one session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% reduction. Report the combined operation once; modifier 50 is inappropriate. Assistant-at-surgery payment requires documented medical necessity. CMS does not recognize co-surgeon or team-surgery billing for this code.
CMS billing rules for 42820
- Global period
- Major surgery with a 90-day global period: the day-before preoperative visit and 90 days of related postoperative care 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
- Assistant at surgery is paid only with documentation of medical necessity.
- Co-surgeons
- Co-surgeons not permitted.
- Team surgery
- Team surgery not permitted.
Where the value comes from
- Work RVU4.11 · 53%
- Practice expense (office) RVU3.11 · 40%
- Malpractice RVU0.59 · 8%
13
Medicare services in 2024 · #6126 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.
42820 compared with similar codes
Office rates for Idaho, from the same CMS release.
No office rate
42825 describes tonsillectomy alone in a patient younger than 12. Choose 42820 when adenoid tissue is also removed in the same session.
No office rate
42830 describes adenoidectomy alone in a patient younger than 12. Choose 42820 when the tonsils are removed during that operation as well.
Compare 42820 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
Idaho →
Office / nonfacility
Unavailable
Facility
$242.17
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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 42820 in Idaho.
PPRRVU2026_Oct_nonQPP.csv
5,079
- Code
- 42820
- Physician work
- 4.11
- Practice expense
- 3.11
- Malpractice
- 0.59
GPCI2026.csv
47
- Locality
- Idaho
- Physician work
- 1.000
- Practice expense
- 0.920
- Malpractice
- 0.473
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 4.11 | × 1.000 | 4.1100 |
| Practice expense | 3.11 | × 0.920 | 2.8612 |
| Malpractice | 0.59 | × 0.473 | 0.2791 |
| Total RVUs | 7.2503 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Idaho$242.17
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 4.11 | 1 |
| Practice expense | 3.11 | 0.92 |
| Malpractice | 0.59 | 0.473 |
(4.11 × 1 + 3.11 × 0.92 + 0.59 × 0.473) × $33.4009 = $242.17
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.
42820 billing questions
How does 42820 differ from 42821?
Both describe removal of the tonsils and adenoids in one session. Use 42820 for a patient younger than 12 on the surgery date and 42821 for a patient age 12 or older.
Can the tonsillectomy and adenoidectomy also be billed separately?
When both are removed in the same session, report the combined code rather than separately reporting the tonsillectomy and adenoidectomy codes for that same work.
What documentation supports reporting 42820?
The operative report should show that both the palatine tonsils and adenoid tissue were removed, and establish the patient's age on the procedure date.
Should modifier 50 be appended?
No. Report the combined operation once; modifier 50 is inappropriate for this code.
When is assistant-at-surgery payment available?
CMS allows assistant-at-surgery payment only when the record documents medical necessity.
How does the global period affect postoperative care?
The 90-day global period includes the day-before preoperative visit and 90 days of related postoperative care.
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.
5,0764280F,,Pcp prophylax rxd 3mon low %,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
5,07742810,,Excision of neck cyst,A,,3.30,7.79,,3.95,,0.47,11.56,7.72,0,090,0.09,0.81,0.10,2,1,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,07842815,,Excision of neck cyst,A,,7.13,6.14,NA,6.14,,1.05,14.32,14.32,0,090,0.09,0.81,0.10,2,1,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,07942820,,Remove tonsils and adenoids,A,,4.11,3.11,NA,3.11,,0.59,7.81,7.81,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08042821,,Remove tonsils and adenoids,A,,4.25,3.29,NA,3.29,,0.61,8.15,8.15,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08142825,,Removal of tonsils,A,,3.42,3.39,NA,3.39,,0.48,7.29,7.29,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08242826,,Removal of tonsils,A,,3.36,3.09,NA,3.09,,0.48,6.93,6.93,0,090,0.09,0.81,0.10,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
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
5006102,IL,15,SUBURBAN CHICAGO,1.007,1.027,1.772