Tonsillectomy and Adenoidectomy

CPT 42826
Approach Endoscopic
Add-on / Variant CPTs
  • 42825 — Tonsillectomy, primary, under age 12
  • 42830 — Adenoidectomy, primary, under age 12
  • 42831 — Adenoidectomy, primary, age 12 or over
  • 42820 — Tonsillectomy and adenoidectomy, under age 12
  • 42821 — Tonsillectomy and adenoidectomy, age 12 or over
Preoperative Diagnosis:

Recurrent tonsillitis / obstructive sleep apnea / tonsillar hypertrophy

Postoperative Diagnosis:

Same

Procedure Performed:

Tonsillectomy and adenoidectomy

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General endotracheal
Patient supine with shoulder roll. Mouth gag (Crowe-Davis) placed for exposure.

Indications:

Patient presents with [recurrent tonsillitis ([X] episodes per year) / obstructive sleep apnea / tonsillar hypertrophy with dysphagia / peritonsillar abscess history]. [Pediatric / adult] patient. [PSG confirmed OSA with AHI [X].] Conservative management failed. Risks including bleeding (primary and secondary), dehydration, velopharyngeal insufficiency (rare), and airway complications discussed. Consent obtained.

Findings:

[Grade [II / III / IV]] tonsillar hypertrophy bilaterally. [Adenoid hypertrophy on nasal endoscopy / lateral neck X-ray.] No evidence of malignancy.

Description of Procedure:

The patient was placed in supine position with a shoulder roll. General anesthesia induced and an oral RAE [or standard] endotracheal tube placed. A Crowe-Davis mouth gag was placed and suspended. Adequate exposure of the oropharynx achieved.
TONSILLECTOMY: The right tonsil was grasped with Allis clamps and retracted medially. The anterior tonsillar pillar was incised with [monopolar cautery / coblation wand]. The tonsil was dissected from the tonsillar fossa in the plane between the tonsillar capsule and the superior pharyngeal constrictor muscle. The inferior pole was released and the tonsil removed. Hemostasis achieved with [suction cautery / coblation]. The procedure was repeated on the left side.
ADENOIDECTOMY: A mirror or 70-degree endoscope was used for visualization of the nasopharynx. [A curette / coblation wand / microdebrider] was used to remove the adenoid tissue from the posterior nasopharynx, with care taken to avoid the Eustachian tube orifices laterally. Hemostasis achieved.
The mouth gag was removed. The oropharynx was inspected with no active bleeding identified. The patient was extubated and taken to PACU.

Complications:

None

Specimens:

[Tonsils sent to pathology / Discarded per institutional protocol]

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

Patient taken to PACU in stable condition. [Same-day discharge / overnight observation for OSA.]

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: [Recurrent tonsillitis / obstructive sleep apnea / tonsillar hypertrophy]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Tonsillectomy and adenoidectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [recurrent tonsillitis (*** episodes per year) / obstructive sleep apnea with AHI *** / tonsillar hypertrophy with dysphagia]. [PSG confirmed OSA.] Conservative management failed. Risks including primary and secondary bleeding, dehydration, and airway complications were discussed. Informed consent obtained.

FINDINGS: Grade [II / III / IV] tonsillar hypertrophy bilaterally. [Adenoid hypertrophy confirmed on nasal endoscopy.] No evidence of malignancy.

DESCRIPTION OF PROCEDURE:
Patient placed supine with shoulder roll. Oral RAE endotracheal tube placed. Crowe-Davis mouth gag placed and suspended with adequate oropharyngeal exposure. TONSILLECTOMY: Right tonsil grasped with Allis clamps; anterior pillar incised with [monopolar cautery / coblation wand]; tonsil dissected from tonsillar fossa between capsule and superior pharyngeal constrictor; inferior pole released; tonsil removed. Hemostasis with suction cautery. Repeated on the left side. ADENOIDECTOMY: Nasopharynx visualized with 70-degree endoscope. [Curette / coblation wand / microdebrider] used to remove adenoid tissue; Eustachian tube orifices preserved bilaterally. Hemostasis confirmed. Mouth gag removed; oropharynx inspected with no active bleeding. Patient extubated and taken to PACU.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Tonsils to pathology / Discarded per institutional protocol]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient taken to PACU in stable condition. [Same-day discharge / Overnight observation for OSA.]

Signed: .ME, .MYDEGREE
.TODAY
Variants

Tonsillectomy only

CPT 42826 (adult) or 42825 (<12). Document adenoid assessment. If not removed, state the reason.

Coblation technique

Document coblation wand settings and dissection technique. Note reduced thermal injury vs. electrocautery.

Intracapsular tonsillectomy (tonsillotomy)

Partial removal preserving capsule. Preferred in young children. CPT 42836. Document partial removal and residual tonsillar tissue.

Charting Tips
  • Document technique (electrocautery, coblation, cold dissection). Each has CPT implications.
  • State age. This drives CPT code selection (<12 vs. ≥12).
  • Adenoidectomy visualization method (mirror vs. endoscope)
  • Hemostasis method at completion (suction cautery, ties, or packing)
  • Specimen to pathology: required if asymmetric tonsils, history of recurrent abscess, or malignancy concern
Billing Tips
  • Bill 42820 for tonsillectomy and adenoidectomy in patients under 12 years (4.11 wRVU, 90-day global). Bill 42821 for patients 12 years and older (4.25 wRVU). Age at time of surgery determines the code.
  • Bill 42825 for tonsillectomy alone (without adenoidectomy) in patients under 12 years (3.42 wRVU). Bill 42826 for tonsillectomy alone in patients 12 and older (3.36 wRVU). If adenoids are also removed, use 42820/42821 instead.
  • Adenoidectomy alone without tonsillectomy uses 42830 (under 12, 2.36 wRVU) or 42831 (12 and older, 2.67 wRVU). Do not bill adenoidectomy separately if it is included in a combined T&A code.
  • 90-day global period: postoperative hemorrhage evaluation (even in the ED) and routine follow-up are bundled. Return to OR for post-tonsillectomy hemorrhage within the global period uses modifier -78.
  • Documentation should include the indication (recurrent tonsillitis, obstructive sleep apnea, peritonsillar abscess), size of tonsils (graded 1-4), adenoid hypertrophy, and technique (hot vs. cold dissection, coblation). Indication affects medical necessity review for payers.