$197.59
42804 describes brush or washing collection from the nasopharynx. This code is for a tissue biopsy performed under direct visualization.
On this page
CMS RVU26D · Effective 2026-10-01
42806 Nasopharyngeal biopsy Medicare reimbursement rates in Iowa
ENT clinicians use this code to obtain tissue from a nasopharyngeal abnormality under direct visualization when surgical biopsy, rather than brush or wash sampling, is performed. Compare 42806 office and facility rates across CMS payment localities in Iowa.
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 42806 in Iowa?
Iowa 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
$220.75
1 of 1 localities have a supported rate.
Payment area: Iowa
One mapped payment locality.
Facility setting
$118.37
1 of 1 localities have a supported rate.
Payment area: Iowa
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 procedure
About 42806: Nasopharyngeal biopsy under direct visualization
ENT clinicians use this code to obtain tissue from a nasopharyngeal abnormality under direct visualization when surgical biopsy, rather than brush or wash sampling, is performed.
An otolaryngologist uses directly visualized surgical instruments to obtain tissue from an abnormal area in the nasopharynx, the space behind the nasal cavity and above the soft palate. Typical indications include a visible mass, irregular mucosa, or other suspicious finding requiring tissue diagnosis. The procedure may be performed in an operating room or another setting where the clinician can directly visualize and sample the target.
Choose this code for a nasopharyngeal tissue biopsy performed under direct visualization; brush or washing-based sampling is represented by a different code. The operative note should identify the nasopharyngeal target, the direct-visualization approach, and the tissue sampling performed. Medicare includes related postoperative visits for 10 days in the procedure’s 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. Medicare does not pay an assistant at surgery for this service, and co-surgeon and team-surgery billing are not permitted.
CMS billing rules for 42806
- 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 RVU1.59 · 22%
- Practice expense (office) RVU5.39 · 75%
- Malpractice RVU0.22 · 3%
97
Medicare services in 2024 · #4908 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.
42806 compared with similar codes
Office rates for Iowa, from the same CMS release.
$146.43
42800 applies to a pharyngeal biopsy. Use this code when the sampled site is in the nasopharynx.
$214.99
42808 describes excision of a pharyngeal lesion. This code is for biopsy sampling of a nasopharyngeal abnormality.
Compare 42806 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
Iowa →
Office / nonfacility
$220.75
Facility
$118.37
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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 42806 in Iowa.
PPRRVU2026_Oct_nonQPP.csv
5,073
- Code
- 42806
- Physician work
- 1.59
- Practice expense
- 5.39
- Malpractice
- 0.22
GPCI2026.csv
53
- Locality
- Iowa
- Physician work
- 1.000
- Practice expense
- 0.915
- Malpractice
- 0.397
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 1.59 | × 1.000 | 1.5900 |
| Practice expense | 5.39 | × 0.915 | 4.9318 |
| Malpractice | 0.22 | × 0.397 | 0.0873 |
| Total RVUs | 6.6092 | ||
| Conversion factor | × 33.4009 | ||
Office / nonfacility rate, Iowa$220.75
Explore RVUs, geographic factors and the full formula
Office / nonfacility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 1.59 | 1 |
| Practice expense | 5.39 | 0.915 |
| Malpractice | 0.22 | 0.397 |
(1.59 × 1 + 5.39 × 0.915 + 0.22 × 0.397) × $33.4009 = $220.75
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 1.59 | 1 |
| Practice expense | 2.04 | 0.915 |
| Malpractice | 0.22 | 0.397 |
(1.59 × 1 + 2.04 × 0.915 + 0.22 × 0.397) × $33.4009 = $118.37
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.
42806 billing questions
How do I distinguish this code from 42804?
Use this code for a directly visualized surgical tissue biopsy of the nasopharynx. Code 42804 describes nasopharyngeal sampling by brush or washings.
When is 42800 a better choice?
Code 42800 is for biopsy of the pharynx. Choose this code when the sampled target is in the nasopharynx and the biopsy is performed under direct visualization.
Does excising a lesion support this biopsy code?
A tissue sample taken for diagnosis supports a biopsy. When the procedure removes a pharyngeal lesion rather than sampling it, compare the documentation with code 42808.
What documentation supports reporting this service?
Document the nasopharyngeal site, the abnormality sampled, direct visualization, and the tissue biopsy performed. The note should distinguish tissue sampling from brush or washing collection.
Are postoperative visits included?
Related postoperative visits during the 10-day global period are included in the procedure.
Can modifier 50 be used for bilateral sampling?
No. CMS identifies bilateral adjustment as inappropriate for this service.
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.
5,0704279F,,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
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
5006102,IL,15,SUBURBAN CHICAGO,1.007,1.027,1.772
5106102,IL,99,REST OF ILLINOIS,1.000,0.913,1.563
5208102,IN,00,INDIANA,1.000,0.927,0.486
5305102,IA,00,IOWA,1.000,0.915,0.397
5405202,KS,00,KANSAS,1.000,0.904,0.504
5515102,KY,00,KENTUCKY,1.000,0.889,0.915
5607202,LA,01,NEW ORLEANS,1.000,0.941,1.136