Billing code 42826: TonsillectomyMedicare rate & RVUs in Washington
Removal of the palatine tonsils in a patient age 12 or older for tonsillar disease or obstruction when a combined tonsil-and-adenoid code is not appropriate.
CMS doesn’t publish an office rate for 42826 in Washington.
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 42826 covers
This code describes surgical removal of the palatine tonsils in a patient who is at least 12 on the date of surgery. Otolaryngologists commonly perform the procedure in a hospital or ambulatory surgery center, often for recurrent tonsillar infections or obstructive tonsillar enlargement. It covers tonsil removal without the adenoidectomy included in a combined tonsil-and-adenoid procedure.
Choose the age-specific code based on the patient’s age on the service date; use the under-12 tonsillectomy code for younger patients. The operative report should support removal of the palatine tonsils and document the indication and any concurrent adenoid procedure. Medicare includes the day-before preoperative visit and 90 days of related postoperative care in the major-surgery global period. 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. Medicare does not pay an assistant at surgery; 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 42826 pays more and less in Washington
| Payment locality | Office | Facility |
|---|---|---|
| Rest Of Washington | Unavailable | $234.57 |
| Seattle (King Cnty) | Unavailable | $257.57 |
How the 42826 rate is calculated
Each of 42826’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 · 42826
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 3.36Practice expense 3.09Malpractice 0.48
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 42826
42826 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42826
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) | 1 | Not paid (statutory restriction). |
| 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 · 42826
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
42826 without 51 · national facility
$231.47
Tonsillectomy
42826-51 · Second procedure: 50%
$115.74
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%).
42826 compared with similar codes
Compare codes
42826 vs 42825 vs 42821 vs 42870: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 42825Tonsillectomy
- Both codes describe tonsil removal; select 42826 for patients age 12 or older and 42825 for patients younger than 12.
- 42821Tonsil and adenoid removal
- 42821 is the combined procedure when both tonsils and adenoids are removed in a patient age 12 or older; 42826 covers tonsil removal alone.
- 42870Tonsil excision
- 42870 addresses excision of lingual tonsil tissue at the base of the tongue, not removal of the palatine tonsils.
42826 billing questions
How does this code differ from 42825?
42826 is for tonsil removal when the patient is age 12 or older on the date of surgery. 42825 is the age-specific code for patients younger than 12.
Should modifier 50 be appended for removal of both tonsils?
No. The code represents the tonsillectomy, and CMS identifies bilateral adjustment as inappropriate.
Which code applies when the adenoids are removed too?
Use the age-appropriate combined tonsil-and-adenoid code when both are removed: 42821 for a patient age 12 or older, or 42820 for a younger patient.
Does the global period include postoperative visits?
Yes. The 90-day major-surgery global period includes the day-before preoperative visit and related postoperative care during the 90 days after surgery.
Can an assistant surgeon or co-surgeon be paid for this procedure?
Medicare does not pay an assistant at surgery for this code. Co-surgeons and team surgery are not permitted.
What happens if another procedure is performed in the same session?
The highest-valued procedure is paid in full, and other procedures are subject to the standard multiple-procedure reduction when performed in the same session.
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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