$148.53–$156.12
Use 42800 for diagnostic biopsy of throat tissue. Use 42870 when lingual tonsil tissue is excised rather than sampled.
On this page
CMS RVU26D · Effective 2026-10-01
42870 Tonsil excision Medicare reimbursement rates in Maine
Reports surgical removal of lingual tonsil tissue, commonly for substantial enlargement at the tongue base contributing to airway obstruction or related symptoms. Compare 42870 office and facility rates across CMS payment localities in Maine.
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 42870 in Maine?
Maine has 2 payment localities in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the 2 payment areas shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$511.08–$535.62
2 of 2 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.
Otolaryngology surgery
About 42870: Lingual tonsil excision
Reports surgical removal of lingual tonsil tissue, commonly for substantial enlargement at the tongue base contributing to airway obstruction or related symptoms.
An otolaryngologist removes lingual tonsil tissue at the base of the tongue, usually in an operating-room setting. The service may be performed for enlarged lingual tonsils associated with airway obstruction, including in a patient being evaluated or treated for obstructive sleep apnea. The operative report should identify the lingual tonsil as the target and describe the excision; removal of palatine tonsils or a biopsy of throat tissue is a different service.
Report this code when lingual tonsil tissue is excised, not when tissue is only sampled. Documentation should establish the operative site and extent of removal. CMS assigns a 90-day global period, including the day-before preoperative visit and 90 days of related postoperative care. 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 for this code. Assistant-at-surgery payment requires documented medical necessity; co-surgeons and team surgery are not permitted.
CMS billing rules for 42870
- 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 RVU5.38 · 33%
- Practice expense (office) RVU10.25 · 62%
- Malpractice RVU0.79 · 5%
153
Medicare services in 2024 · #4546 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.
42870 compared with similar codes
Office rates for Maine, from the same CMS release.
$218.35–$228.84
42808 addresses excision of a pharyngeal lesion. This code is specific to removal of lingual tonsil tissue at the tongue base.
No office rate
42825 is for removal of palatine tonsils in a younger patient. Choose 42870 when the operative target is the lingual tonsil.
No office rate
42826 is for removal of palatine tonsils in an older patient. It does not describe excision of lingual tonsil tissue.
Compare 42870 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.
2 of 2 payment localities
Rest Of Maine →
Office / nonfacility
Unavailable
Facility
$511.08
Southern Maine →
Office / nonfacility
Unavailable
Facility
$535.62
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42870 billing questions
How is this different from palatine tonsillectomy?
This code is for lingual tonsil tissue at the tongue base. Palatine tonsillectomy codes apply to the tonsils on the sides of the throat.
Can this code be used for a biopsy?
No. It reports excision of lingual tonsil tissue. A throat-tissue biopsy is a different service when the intent is diagnostic sampling rather than removal.
Should modifier 50 be appended for both sides?
No. CMS identifies bilateral adjustment as inappropriate for this code, so modifier 50 should not be used.
How are other procedures in the same session paid?
The highest-valued procedure is paid in full, and other procedures in the session are subject to the standard multiple-procedure reduction.
When may an assistant at surgery be reported?
Assistant-at-surgery payment is allowed only when medical necessity is documented. Co-surgeons and team surgery are not permitted for this code.
What postoperative care is included?
The 90-day global period includes the day-before preoperative visit and related postoperative care during the 90 days after surgery.
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.
5,08842844,,Extensive surgery of throat,A,,17.34,16.83,NA,16.83,,2.61,36.78,36.78,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08942845,,Extensive surgery of throat,A,,31.75,21.39,NA,21.39,,4.64,57.78,57.78,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,09042860,,Excision of tonsil tags,A,,2.24,2.80,NA,2.80,,0.34,5.38,5.38,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,09142870,,Excision of lingual tonsil,A,,5.38,10.25,NA,10.25,,0.79,16.42,16.42,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,09242890,,Limited pharyngectomy,A,,18.65,16.17,NA,16.17,,2.76,37.58,37.58,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,09342892,,Revision of pharyngeal walls,A,,25.38,20.06,NA,20.06,,3.70,49.14,49.14,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,09442894,,Revision of pharyngeal walls,A,,33.07,24.14,NA,24.14,,4.84,62.05,62.05,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00