Billing code 42860: Tonsil tag excisionMedicare rate & RVUs in Ohio
Reports surgical removal of a tonsillar tag, rather than a throat biopsy, pharyngeal lesion excision, or removal of the tonsils.
CMS doesn’t publish an office rate for 42860 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 42860 covers
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.
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 in Ohio
| Payment locality | Office | Facility |
|---|---|---|
| Ohio | Unavailable | $171.65 |
How the 42860 rate is calculated
Each of 42860’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 · 42860
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 2.24Practice expense 2.80Malpractice 0.34
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 42860
42860 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42860
Tonsil tag excision
| 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 · 42860
Tonsil tag excision
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
42860 without 51 · national facility
$179.70
Tonsil tag excision
42860-51 · Second procedure: 50%
$89.85
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%).
42860 compared with similar codes
Compare codes
42860 vs 42800 vs 42808 vs 42825: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 42800Biopsy
- 42800 describes biopsy of throat tissue. Choose 42860 when the tonsil tag itself is excised rather than sampled.
- 42808Pharyngeal lesion treatment
- 42808 is for excision of a pharyngeal lesion. 42860 identifies removal of a tonsil tag; document the precise site and tissue treated.
- 42825Tonsillectomy
- 42825 describes tonsil removal. Use 42860 for excision limited to a tonsil tag, not removal of the tonsils.
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 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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