Billing code 42800: BiopsyMedicare rate & RVUs in Illinois
Reports sampling of a suspected pharyngeal lesion for tissue diagnosis, typically by an otolaryngologist during office evaluation or an operative examination.
Medicare pays $154.39–$169.60 for 42800 in the office in Illinois, from Rest Of Illinois to Chicago. 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 42800 covers
An otolaryngologist takes a tissue sample from an abnormal area of the pharynx for diagnostic examination. The service is used when inspection identifies a lesion or mucosal change that needs tissue diagnosis; the biopsy samples tissue rather than removing the lesion as definitive treatment. It may be performed in an office or an operating room, depending on access and the clinical circumstances.
Report the code when the documented service is a pharyngeal biopsy, not a biopsy of a nasopharyngeal lesion or therapeutic excision. The record should identify the pharyngeal site, the abnormality prompting sampling, and the tissue obtained. Medicare assigns a 10-day global period, which includes related postoperative visits during that period. For multiple procedures in one session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% reduction. Do not use modifier 50 for bilateral adjustment. Medicare does not pay an assistant at surgery for this service; 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 42800 pays more and less in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
4 payment localities
$154.39 to $169.60
| Payment locality | Office | Facility |
|---|---|---|
| Chicago | $169.60 | $115.89 |
| East St. Louis | $158.30 | $109.13 |
| Rest Of Illinois | $154.39 | $105.60 |
| Suburban Chicago | $168.26 | $113.37 |
How the 42800 rate is calculated
Each of 42800’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 · 42800
RVUs × geographic indexes × conversion factor
Work1.40
1.40 RVUs× 1.000 GPCI
Practice expense3.17
3.17 RVUs× 1.000 GPCI
Malpractice0.21
0.21 RVUs× 1.000 GPCI
Adjusted RVUs
4.7800
Conversion factor
$33.4009
Medicare rate
$159.66
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 42800
42800 has a 10-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42800
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 · 42800
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
42800 without 51 · national office
$159.66
Biopsy
42800-51 · Second procedure: 50%
$79.83
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%).
42800 compared with similar codes
Compare codes · National
4 codes, side by side
How to choose
- 42804Nasopharyngeal biopsy
- 42800 is for biopsy in the pharynx; 42804 is for a visible lesion in the nasopharynx.
- 42806Nasopharyngeal biopsy
- 42806 concerns a nasopharyngeal biopsy in a different operative circumstance. Confirm the exact biopsy site and service documented.
- 42808Pharyngeal lesion treatment
- 42800 samples tissue for diagnosis. 42808 is for excising a pharyngeal lesion, not simply obtaining a biopsy specimen.
42800 billing questions
How does this differ from a nasopharyngeal biopsy?
Use 42800 for a biopsy in the pharynx. Codes 42804 and 42806 describe biopsies of the nasopharynx, so the documented site determines the choice.
Can this code represent complete removal of a pharyngeal lesion?
It represents tissue sampling for diagnosis, not therapeutic removal of the lesion. When the lesion is excised, consider 42808 if its service and site criteria are met.
How are other procedures in the same session paid?
Under the standard multiple procedure reduction, Medicare pays the highest-valued procedure in full and applies a 50% reduction to the others.
Should modifier 50 be used for biopsies on both sides?
No. Bilateral adjustment is inappropriate for this code's descriptor or anatomy; do not append modifier 50.
What documentation supports reporting this biopsy?
Document the pharyngeal site, the lesion or abnormality prompting the biopsy, and the tissue sampled. Related postoperative visits during the 10-day global period are included.
Can an assistant, co-surgeon, or surgical team be billed?
Medicare does not pay an assistant at surgery for this service. Co-surgeons and team surgery are not permitted.
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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