No office rate
Both are primary adenoidectomies; 42831 is for patients age 12 or older, while 42830 is for patients younger than 12.
On this page
CMS RVU26D · Effective 2026-10-01
42831 Adenoidectomy Medicare reimbursement rates in Wisconsin
Reports primary removal of adenoid tissue in a patient age 12 or older, commonly for obstructive symptoms or recurrent adenoid-related disease. Compare 42831 office and facility rates across CMS payment localities in Wisconsin.
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 42831 in Wisconsin?
Wisconsin 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
$198.99
1 of 1 localities have a supported rate.
Payment area: Wisconsin
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.
Otolaryngology surgery
About 42831: Primary adenoidectomy, age 12 or older
Reports primary removal of adenoid tissue in a patient age 12 or older, commonly for obstructive symptoms or recurrent adenoid-related disease.
An otolaryngologist removes adenoid tissue located behind the nasal cavity, commonly to address nasal blockage, sleep-disordered breathing, or recurrent adenoid-related inflammation. The procedure is generally performed in a surgical facility under anesthesia. This code identifies a primary adenoidectomy in a patient who is at least 12 years old; it is not the code for repeat removal of residual or regrown tissue.
Choose the code based on the patient’s age and whether the adenoidectomy is primary or secondary. The operative report should support removal of adenoid tissue and the procedure’s primary status. CMS treats the service as major surgery with a 90-day global period, including the day-before preoperative visit and 90 days of related postoperative care. When multiple procedures occur in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% reduction. Modifier 50 is inappropriate. Assistant-at-surgery payment requires documented medical necessity; co-surgeons and team surgery are not permitted.
CMS billing rules for 42831
- 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 RVU2.74 · 43%
- Practice expense (office) RVU3.23 · 51%
- Malpractice RVU0.40 · 6%
197
Medicare services in 2024 · #4339 by national volume
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.
42831 compared with similar codes
Office rates for Wisconsin, from the same CMS release.
No office rate
42836 is for secondary adenoidectomy in a patient age 12 or older, such as repeat removal; 42831 is for primary removal.
No office rate
Use 42821 when both tonsils and adenoids are removed in a patient age 12 or older; 42831 describes primary adenoid removal alone.
Compare 42831 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
Wisconsin →
Office / nonfacility
Unavailable
Facility
$198.99
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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 42831 in Wisconsin.
PPRRVU2026_Oct_nonQPP.csv
5,084
- Code
- 42831
- Physician work
- 2.74
- Practice expense
- 3.23
- Malpractice
- 0.40
GPCI2026.csv
111
- Locality
- Wisconsin
- Physician work
- 1.000
- Practice expense
- 0.958
- Malpractice
- 0.308
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 2.74 | × 1.000 | 2.7400 |
| Practice expense | 3.23 | × 0.958 | 3.0943 |
| Malpractice | 0.40 | × 0.308 | 0.1232 |
| Total RVUs | 5.9575 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Wisconsin$198.99
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 2.74 | 1 |
| Practice expense | 3.23 | 0.958 |
| Malpractice | 0.4 | 0.308 |
(2.74 × 1 + 3.23 × 0.958 + 0.4 × 0.308) × $33.4009 = $198.99
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.
42831 billing questions
How does 42831 differ from 42830?
Both describe primary adenoidectomy. Use 42831 for a patient age 12 or older and 42830 for a patient younger than 12.
When is 42836 used instead?
42836 describes secondary adenoidectomy for a patient age 12 or older, such as a repeat procedure for residual or regrown adenoid tissue. Code 42831 is for primary removal.
Should 42831 be reported with a tonsillectomy code when both are removed?
When the surgeon removes both the adenoids and tonsils, compare the age-appropriate combined adenotonsillectomy code, 42821 for age 12 or older, rather than treating the services as adenoidectomy alone.
Can modifier 50 be appended for adenoid removal?
No. The CMS bilateral adjustment does not apply to this code, and modifier 50 is inappropriate.
What documentation supports reporting 42831?
The operative report should document primary removal of adenoid tissue, and the record should establish that the patient was at least 12 years old on the service date.
When is assistant-at-surgery payment allowed?
CMS allows assistant-at-surgery payment only when medical necessity is documented. 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 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.
5,08142825,,Removal of tonsils,A,,3.42,3.39,NA,3.39,,0.48,7.29,7.29,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08242826,,Removal of tonsils,A,,3.36,3.09,NA,3.09,,0.48,6.93,6.93,0,090,0.09,0.81,0.10,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08342830,,Removal of adenoids,A,,2.58,2.89,NA,2.89,,0.38,5.85,5.85,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08442831,,Removal of adenoids,A,,2.74,3.23,NA,3.23,,0.40,6.37,6.37,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08542835,,Removal of adenoids,A,,2.32,2.82,NA,2.82,,0.35,5.49,5.49,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08642836,,Removal of adenoids,A,,3.18,3.03,NA,3.03,,0.46,6.67,6.67,0,090,0.09,0.81,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,08742842,,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
10802402,WA,02,SEATTLE (KING CNTY),1.050,1.227,0.817
10902402,WA,99,REST OF WASHINGTON,1.013,1.053,0.761
11011402,WV,16,WEST VIRGINIA,1.000,0.869,1.431
11106302,WI,00,WISCONSIN,1.000,0.958,0.308
11203602,WY,21,WYOMING**,1.000,1.000,0.740
113"MAC Assignments as of November 22, 2023",,,,,,
114,,,,,,