CPT 42804
Global 010 ActiveBiopsy of upper nose/throat
CPT 42804 Billing & Documentation Guide
CPT code 42804 (Biopsy of upper nose/throat) is classified under Surgery (Digestive) with a global period indicator of 010. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 1.26, a non-facility practice expense RVU of 5.01, and a malpractice RVU of 0.18, a total non-facility RVU of 6.45 and facility RVU of 3.38. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $222.73, though rates vary from $188.93 to $291.24 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 42804, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 42804 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
10-day global period (minor procedure: pre-op day + procedure + 10 days post-op)
MUE Limit (Medically Unlikely Edits)
Submitting more than 1 units of 42804 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 42804
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 1.26 | 1.26 |
| Practice Expense RVU | 5.01 | 1.94 |
| Malpractice RVU | 0.18 | 0.18 |
| Total RVU | 6.45 | 3.38 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 42804
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $244.86 | $123.53 | $229.43 - $291.24 | 29 |
| Florida | $221.69 | $118.8 | $211.1 - $231.49 | 3 |
| Georgia | $208.99 | $111.16 | $198.52 - $219.45 | 2 |
| Illinois | $215.41 | $116.33 | $204.26 - $224.89 | 4 |
| Michigan | $207.68 | $111.39 | $201.65 - $213.7 | 2 |
| North Carolina | $202.05 | $106.38 | $202.05 - $202.05 | 1 |
| New York | $238.94 | $124.54 | $205.28 - $254.91 | 5 |
| Ohio | $200.93 | $107.31 | $200.93 - $200.93 | 1 |
| Pennsylvania | $212.8 | $112.36 | $201.38 - $224.21 | 2 |
| Texas | $212.65 | $111.69 | $199.95 - $224.54 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 42804
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 42804 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 00170 | Column 1 (primary), can be billed with modifier | No | Anesthesia service included in surgical procedure |
| 0213T | Column 1 (primary), can be billed with modifier | No | Misuse of Column Two code with Column One code |
| 0216T | Column 1 (primary), can be billed with modifier | No | Misuse of Column Two code with Column One code |
| 0228T | Column 1 (primary), can be billed with modifier | No | Standards of medical/surgical practice |
| 0230T | Column 1 (primary), can be billed with modifier | No | Standards of medical/surgical practice |
| 0596T | Column 1 (primary), can be billed with modifier | Yes | Standards of medical/surgical practice |
| 0597T | Column 1 (primary), can be billed with modifier | Yes | Standards of medical/surgical practice |
| 0708T | Column 1 (primary), can be billed with modifier | Yes | Standards of medical/surgical practice |
| 0709T | Column 1 (primary), can be billed with modifier | Yes | Standards of medical/surgical practice |
| 0903T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 42804
What does CPT code 42804 mean? +
CPT code 42804 represents: Biopsy of upper nose/throat. It's in the Surgery (Digestive) category with a global period of 010.
What is the Medicare reimbursement for CPT 42804? +
The 2026 Medicare national average non-facility payment for CPT 42804 is $222.73. Rates range from $188.93 to $291.24 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 42804? +
Surgery codes commonly use modifier 22 (increased procedural services), 50 (bilateral), 51 (multiple procedures), 52 (reduced services), 58/78/79 (staged, unplanned return, unrelated within global), 62 (co-surgeons), 80/82 (assistant surgeon), and 59 or the X{EPSU} subset for distinct procedural service.
What bundling edits apply to CPT 42804? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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