Billing code 42825: TonsillectomyMedicare rate & RVUs in Ohio
Reports surgical removal of the palatine tonsils in a patient younger than 12, commonly for recurrent infection or tonsillar obstruction.
CMS doesn’t publish an office rate for 42825 in Ohio.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 42825 covers
An otolaryngologist typically performs this operation in an operating room, removing the palatine tonsils in a patient younger than 12. Common clinical reasons include recurrent or chronic tonsillitis and enlarged tonsils associated with obstructive breathing or sleep-disordered breathing. The operation addresses the tonsils; removal of adenoid tissue is a separate distinction in code selection.
Select this code based on the patient’s age on the date of surgery and the documented procedure. The operative report should support removal of the palatine tonsils and identify any additional procedure, such as adenoid removal. This major surgery includes the preoperative visit on the day before and related postoperative care for 90 days. For multiple procedures in the same session, CMS pays the highest-valued procedure in full and other procedures at 50%. Do not append modifier 50. Assistant-at-surgery payment requires documentation of medical necessity; co-surgeons and team surgery are not permitted.
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.
42825 in Ohio
| Payment locality | Office | Facility |
|---|---|---|
| Ohio | Unavailable | $233.77 |
How the 42825 rate is calculated
Each of 42825’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 42825
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 3.42Practice expense 3.39Malpractice 0.48
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 42825
42825 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42825
Tonsillectomy
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 090 | Major surgery: the day before, the day of, and 90 days after are included. |
| Multiple procedures | 2 | Standard reduction: highest-valued procedure at 100%, others at 50%. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 0 | Not paid without supporting documentation. |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
| Split (54/55/56) | 0.09/0.81/0.10 | Share of the payment for pre-op, the procedure itself, and post-op care. |
Global surgery period · 42825
Tonsillectomy
90-day global period ends
Dec 30, 2026
Covers Sep 30, 2026 through Dec 30, 2026 (92 days, including the day before surgery).
Visit on Oct 31, 2026
Day 30 of the 90-day post-op period: related follow-up care is included in the surgical payment.
Pre-op dayGlobal period
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
42825 without 51 · national facility
$243.49
Tonsillectomy
42825-51 · Second procedure: 50%
$121.75
When this isn’t the highest-valued procedure in the session, Medicare pays 50% of its fee schedule amount (the highest is paid at 100%).
42825 compared with similar codes
Compare codes
42825 vs 42826 vs 42820 vs 42830: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 42826Tonsillectomy
- The procedure is tonsil removal in both codes; age determines the choice. Use 42825 below age 12 and 42826 at age 12 or older.
- 42820Tonsil and adenoid removal
- This code includes removal of both tonsils and adenoids in a patient younger than 12. Choose 42825 when the documented operation removes the tonsils only.
- 42830Adenoid removal
- This code reports adenoid removal without tonsil removal. It is not the choice when the surgeon removes the palatine tonsils.
42825 billing questions
How does this code differ from 42826?
Both report tonsil removal, but 42825 is for patients younger than 12. Use 42826 for patients age 12 or older.
Can modifier 50 be reported for removal of both tonsils?
No. The CMS bilateral adjustment does not apply, and modifier 50 is inappropriate for this code.
When should 42820 be considered instead?
Use 42820 when the surgeon removes both the tonsils and adenoids in a patient younger than 12. This code covers tonsil removal without the adenoid procedure.
What documentation supports reporting 42825?
The operative report should document removal of the palatine tonsils, and the record should establish that the patient was younger than 12 on the surgery date.
How does the 90-day global period affect postoperative billing?
The day-before preoperative visit and related postoperative care during the 90 days after surgery are included in the global period.
Can an assistant surgeon be reported?
Assistant-at-surgery payment is available only when the record documents medical necessity. 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 indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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