$152.28
42800 describes biopsy of throat tissue. Choose 42860 when the tonsil tag itself is excised rather than sampled.
On this page
CMS RVU26D · Effective 2026-10-01
42860 Tonsil tag excision Medicare reimbursement rates in New Mexico
Reports surgical removal of a tonsillar tag, rather than a throat biopsy, pharyngeal lesion excision, or removal of the tonsils. Compare 42860 office and facility rates across CMS payment localities in New Mexico.
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 42860 in New Mexico?
New Mexico 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
$174.22
1 of 1 localities have a supported rate.
Payment area: New Mexico
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.
ENT surgery
About 42860: Tonsillar tag excision
Reports surgical removal of a tonsillar tag, rather than a throat biopsy, pharyngeal lesion excision, or removal of the tonsils.
An otolaryngologist removes a discrete tag of tissue associated with the tonsil, typically when it is symptomatic or requires removal. The procedure may be performed in an operating room or another appropriate surgical setting; the operative note should identify the tag’s location and describe the tissue excised. This code is for removal of the tag itself, not sampling alone or removal of the tonsils.
Report the service when the documented work is excision of tonsil-tag tissue. The record should support the indication, site, and extent of the excision. CMS assigns a 90-day global period, including the day-before preoperative visit and 90 days of related postoperative care. When other procedures are performed in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard multiple-procedure reduction. Modifier 50 is inappropriate. Assistant-at-surgery payment requires documentation of medical necessity; co-surgeons and team surgery are not permitted.
CMS billing rules for 42860
- 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 RVU2.24 · 42%
- Practice expense (office) RVU2.80 · 52%
- Malpractice RVU0.34 · 6%
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.
42860 compared with similar codes
Office rates for New Mexico, from the same CMS release.
$224.68
42808 is for excision of a pharyngeal lesion. 42860 identifies removal of a tonsil tag; document the precise site and tissue treated.
No office rate
42825 describes tonsil removal. Use 42860 for excision limited to a tonsil tag, not removal of the tonsils.
Compare 42860 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
New Mexico →
Office / nonfacility
Unavailable
Facility
$174.22
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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 42860 in New Mexico.
PPRRVU2026_Oct_nonQPP.csv
5,090
- Code
- 42860
- Physician work
- 2.24
- Practice expense
- 2.80
- Malpractice
- 0.34
GPCI2026.csv
77
- Locality
- New Mexico
- Physician work
- 1.000
- Practice expense
- 0.917
- Malpractice
- 1.201
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 2.24 | × 1.000 | 2.2400 |
| Practice expense | 2.80 | × 0.917 | 2.5676 |
| Malpractice | 0.34 | × 1.201 | 0.4083 |
| Total RVUs | 5.2159 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, New Mexico$174.22
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 2.24 | 1 |
| Practice expense | 2.8 | 0.917 |
| Malpractice | 0.34 | 1.201 |
(2.24 × 1 + 2.8 × 0.917 + 0.34 × 1.201) × $33.4009 = $174.22
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.
42860 billing questions
How is this different from a throat biopsy?
Use 42860 when the tonsil tag is excised. A throat biopsy code is for obtaining a sample rather than removing a tag as the procedure.
Is routine postoperative care separately reported?
Related postoperative care during the 90-day global period is included, as is the day-before preoperative visit.
Should modifier 50 be used for tags on both sides?
No. CMS identifies bilateral adjustment as inappropriate for this code.
When can an assistant-at-surgery be paid?
Only when the record documents medical necessity for the assistant.
Can co-surgeons or a surgical team report this service?
CMS does not permit co-surgeons or team surgery for this code.
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.
5,08742842,,Extensive surgery of throat,A,,11.92,13.58,NA,13.58,,1.77,27.27,27.27,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08842844,,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
7414312,NH,40,NEW HAMPSHIRE,1.000,1.041,0.875
7512402,NJ,01,NORTHERN NJ,1.063,1.160,1.068
7612402,NJ,99,REST OF NEW JERSEY,1.040,1.092,1.097
7704212,NM,05,NEW MEXICO,1.000,0.917,1.201
7813202,NY,01,MANHATTAN,1.064,1.162,1.586
7913202,NY,02,NYC SUBURBS/LONG ISLAND,1.064,1.189,1.857
8013202,NY,03,POUGHKPSIE/N NYC SUBURBS,1.045,1.095,1.210