No office rate
Use 42820 for combined tonsil and adenoid removal in a patient younger than 12; 42821 is for age 12 or older.
On this page
CMS RVU26D · Effective 2026-10-01
42821 Tonsil and adenoid removal Medicare reimbursement rates in Kentucky
Reports removal of both the tonsils and adenoids in a patient age 12 or older, commonly for recurrent infection or obstructive symptoms. Compare 42821 office and facility rates across CMS payment localities in Kentucky.
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 42821 in Kentucky?
Kentucky 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
$258.29
1 of 1 localities have a supported rate.
Payment area: Kentucky
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 42821: Tonsillectomy and adenoidectomy, age 12 or older
Reports removal of both the tonsils and adenoids in a patient age 12 or older, commonly for recurrent infection or obstructive symptoms.
An otolaryngologist removes the palatine tonsils and adenoid tissue during the same operation. Common clinical settings include surgery for recurrent tonsillitis or adenotonsillar enlargement associated with obstructive sleep-disordered breathing. The code applies when the patient is 12 or older and both sites are treated; tonsil removal alone or adenoid removal alone calls for a different code. These procedures are typically performed in a facility operating room.
The operative report should identify the patient’s age and document removal of both the tonsils and adenoids, along with the clinical reason. The combined procedure is reported as one service rather than as separate tonsil and adenoid procedures. It has a 90-day global period, including the day-before preoperative visit and related postoperative care. For other procedures performed in the same session, the highest-valued procedure is paid in full and additional procedures are subject to the standard 50% multiple-procedure reduction. Modifier 50 is inappropriate. Assistant-at-surgery payment requires documented medical necessity; co-surgeon and team-surgery billing are not permitted.
CMS billing rules for 42821
- 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 RVU4.25 · 52%
- Practice expense (office) RVU3.29 · 40%
- Malpractice RVU0.61 · 7%
164
Medicare services in 2024 · #4494 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.
42821 compared with similar codes
Office rates for Kentucky, from the same CMS release.
No office rate
42826 covers tonsil removal alone in a patient age 12 or older. Use 42821 when adenoid tissue is also removed.
No office rate
42831 covers primary adenoid removal alone in a patient age 12 or older. Use 42821 when the tonsils are removed during the same operation.
Compare 42821 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
Kentucky →
Office / nonfacility
Unavailable
Facility
$258.29
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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 42821 in Kentucky.
PPRRVU2026_Oct_nonQPP.csv
5,080
- Code
- 42821
- Physician work
- 4.25
- Practice expense
- 3.29
- Malpractice
- 0.61
GPCI2026.csv
55
- Locality
- Kentucky
- Physician work
- 1.000
- Practice expense
- 0.889
- Malpractice
- 0.915
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 4.25 | × 1.000 | 4.2500 |
| Practice expense | 3.29 | × 0.889 | 2.9248 |
| Malpractice | 0.61 | × 0.915 | 0.5582 |
| Total RVUs | 7.7330 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Kentucky$258.29
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 4.25 | 1 |
| Practice expense | 3.29 | 0.889 |
| Malpractice | 0.61 | 0.915 |
(4.25 × 1 + 3.29 × 0.889 + 0.61 × 0.915) × $33.4009 = $258.29
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.
42821 billing questions
How does this code differ from 42820?
Both codes cover removal of tonsils and adenoids in the same operation. Use 42821 for patients age 12 or older; 42820 is for patients younger than 12.
Can tonsil and adenoid removal be billed as separate procedures?
When both are removed in the same operation for a patient age 12 or older, report the combined service. Use a tonsil-only or adenoid-only code when only that tissue is removed.
Should modifier 50 be appended?
No. The bilateral adjustment does not apply to this service, and modifier 50 is inappropriate for the paired tonsils.
What postoperative care is included?
The 90-day global period includes the day-before preoperative visit and 90 days of related postoperative care.
When can an assistant surgeon be reported?
Assistant-at-surgery payment is allowed only when medical necessity is documented. 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 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.
5,07742810,,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
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
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
5707202,LA,99,REST OF LOUISIANA,1.000,0.885,0.958
5814112,ME,03,SOUTHERN MAINE,1.000,0.991,0.631