CPT code 42160: Palate lesion treatment2026 Medicare rate & RVUs in Washington
Reports destruction of a lesion on the palate or uvula, such as treatment using laser or cautery rather than biopsy or excision.
Medicare pays $240.24–$271.59 for 42160 in the office in Washington, from Rest Of Washington to Seattle (King Cnty). Which amount applies depends on the service address.
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 42160 covers
This service destroys a lesion on the roof of the mouth or uvula, using a method such as laser or cautery. Otolaryngologists and oral surgeons may perform it in an office or operating room when the treatment plan is to destroy the lesion rather than remove tissue for examination or excise it surgically. The site and treatment method distinguish this service from biopsy and excision codes for the same area.
Document the lesion’s location and the destruction performed. The code has a 10-day global period, so related postoperative visits during that period are included. 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 service. Assistant-at-surgery payment requires documented 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.
Where 42160 pays more and less in Washington
| Payment locality | Office | Facility |
|---|---|---|
| Rest Of Washington | $240.24 | $131.21 |
| Seattle (King Cnty) | $271.59 | $144.54 |
How the 42160 rate is calculated
Each of 42160’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 · 42160
RVUs × geographic indexes × conversion factor
Work1.80
1.80 RVUs× 1.000 GPCI
Practice expense4.94
4.94 RVUs× 1.000 GPCI
Malpractice0.22
0.22 RVUs× 1.000 GPCI
Adjusted RVUs
6.9600
Conversion factor
$33.4009
Medicare rate
$232.47
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 42160
42160 has a 10-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42160
Palate lesion treatment
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 010 | Minor procedure: the day of the procedure plus 10 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) | 0.10/0.80/0.10 | Share of the payment for pre-op, the procedure itself, and post-op care. |
Global surgery period · 42160
Palate lesion treatment
10-day global period ends
Oct 11, 2026
Covers Oct 1, 2026 through Oct 11, 2026 (11 days).
Visit on Oct 31, 2026
After the global period ends: visits and procedures are billed normally.
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
42160 without 51 · national office
$232.47
Palate lesion treatment
42160-51 · Second procedure: 50%
$116.24
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%).
42160 compared with similar codes
Compare codes · National
4 codes, side by side
How to choose
- 42100Palate biopsy
- 42100 is for biopsy of the roof of the mouth. Report 42160 when the lesion is treated by destruction rather than sampled for examination.
- 42104Palatal excision
- 42104 describes excision of a palate lesion. Use 42160 for a destruction method such as laser or cautery, not surgical removal.
- 42106Palate excision
- 42106 is another palate-lesion excision option. The key distinction is excision of tissue versus destruction of the lesion with 42160.
42160 billing questions
When should this code be chosen over a palate biopsy code?
Use this code when the lesion is destroyed, for example with laser or cautery. A biopsy code describes tissue sampling for examination.
How does this differ from palate lesion excision?
This code represents destruction of the lesion. Choose an excision code when the service removes the lesion surgically rather than destroying it.
Are related postoperative visits separately reported?
Related postoperative visits during the 10-day global period are included in this procedure’s payment.
How are other procedures performed in the same session paid?
The highest-valued procedure is paid in full; other procedures in the session are subject to the standard multiple-procedure reduction.
Can modifier 50 or an assistant-at-surgery claim be used?
Modifier 50 is inappropriate for this service. Assistant-at-surgery payment requires documentation of medical necessity.
Can co-surgeons or a surgical team report this service?
Co-surgeons and team surgery are not permitted 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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