No office rate
Both codes describe tonsil removal; select 42826 for patients age 12 or older and 42825 for patients younger than 12.
On this page
CMS RVU26D · Effective 2026-10-01
42826 Tonsillectomy Medicare reimbursement rates in Illinois
Removal of the palatine tonsils in a patient age 12 or older for tonsillar disease or obstruction when a combined tonsil-and-adenoid code is not appropriate. Compare 42826 office and facility rates across CMS payment localities in Illinois.
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 42826 in Illinois?
Illinois has 4 payment localities in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the 4 payment areas shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$231.52–$253.53
4 of 4 localities have a supported rate.
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.
Where 42826 pays more and less in Illinois
Otolaryngology surgery
About 42826: Tonsillectomy, age 12 or older
Removal of the palatine tonsils in a patient age 12 or older for tonsillar disease or obstruction when a combined tonsil-and-adenoid code is not appropriate.
This code describes surgical removal of the palatine tonsils in a patient who is at least 12 on the date of surgery. Otolaryngologists commonly perform the procedure in a hospital or ambulatory surgery center, often for recurrent tonsillar infections or obstructive tonsillar enlargement. It covers tonsil removal without the adenoidectomy included in a combined tonsil-and-adenoid procedure.
Choose the age-specific code based on the patient’s age on the service date; use the under-12 tonsillectomy code for younger patients. The operative report should support removal of the palatine tonsils and document the indication and any concurrent adenoid procedure. Medicare includes the day-before preoperative visit and 90 days of related postoperative care in the major-surgery 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. Modifier 50 is inappropriate. Medicare does not pay an assistant at surgery; co-surgeons and team surgery are not permitted.
CMS billing rules for 42826
- 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
- 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 RVU3.36 · 48%
- Practice expense (office) RVU3.09 · 45%
- Malpractice RVU0.48 · 7%
1.6K
Medicare services in 2024 · #2618 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.
42826 compared with similar codes
Office rates for Illinois, from the same CMS release.
No office rate
42821 is the combined procedure when both tonsils and adenoids are removed in a patient age 12 or older; 42826 covers tonsil removal alone.
No office rate
42870 addresses excision of lingual tonsil tissue at the base of the tongue, not removal of the palatine tonsils.
Compare 42826 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.
4 of 4 payment localities
Chicago →
Office / nonfacility
Unavailable
Facility
$253.53
East St. Louis →
Office / nonfacility
Unavailable
Facility
$239.47
Rest Of Illinois →
Office / nonfacility
Unavailable
Facility
$231.52
Suburban Chicago →
Office / nonfacility
Unavailable
Facility
$247.42
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42826 billing questions
How does this code differ from 42825?
42826 is for tonsil removal when the patient is age 12 or older on the date of surgery. 42825 is the age-specific code for patients younger than 12.
Should modifier 50 be appended for removal of both tonsils?
No. The code represents the tonsillectomy, and CMS identifies bilateral adjustment as inappropriate.
Which code applies when the adenoids are removed too?
Use the age-appropriate combined tonsil-and-adenoid code when both are removed: 42821 for a patient age 12 or older, or 42820 for a younger patient.
Does the global period include postoperative visits?
Yes. The 90-day major-surgery global period includes the day-before preoperative visit and related postoperative care during the 90 days after surgery.
Can an assistant surgeon or co-surgeon be paid for this procedure?
Medicare does not pay an assistant at surgery for this code. Co-surgeons and team surgery are not permitted.
What happens if another procedure is performed in the same session?
The highest-valued procedure is paid in full, and other procedures are subject to the standard multiple-procedure reduction when performed in the same session.
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.
5,07942820,,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
5,08342830,,Removal of adenoids,A,,2.58,2.89,NA,2.89,,0.38,5.85,5.85,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08442831,,Removal of adenoids,A,,2.74,3.23,NA,3.23,,0.40,6.37,6.37,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08542835,,Removal of adenoids,A,,2.32,2.82,NA,2.82,,0.35,5.49,5.49,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00