Tonsillectomy and Adenoidectomy

CPT 42821 · 4.25 wRVU · 90-day global
CPT42821
wRVU4.25
Global90-day
ApproachEndoscopic
ComplexityModerate
Add-on / Variant CPTs
  • 42825 wRVU: 3.42 — Tonsillectomy, primary, under age 12
  • 42830 wRVU: 2.58 — Adenoidectomy, primary, under age 12
  • 42831 wRVU: 2.74 — Adenoidectomy, primary, age 12 or over
  • 42820 wRVU: 4.11 — Tonsillectomy and adenoidectomy, under age 12
  • 42821 wRVU: 4.25 — 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

Indications:

Patient presents with [recurrent tonsillitis meeting AAO-HNS Paradise criteria: [7 or more episodes in the past year / 5 or more per year for 2 consecutive years / 3 or more per year for 3 consecutive years], each documented with at least one of [temperature >38.3 C / cervical lymphadenopathy / tonsillar exudate / positive GABHS test] / obstructive sleep apnea [with AHI [X] on PSG] / tonsillar hypertrophy with dysphagia / peritonsillar abscess history]. [Pediatric / adult] patient. Conservative management failed. Risks including primary bleeding (~0.5-2%) and secondary bleeding (~2-4%), dehydration, velopharyngeal insufficiency (rare), and airway complications discussed. Intraoperative dexamethasone planned for PONV prophylaxis. 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. Dexamethasone [0.5 mg/kg IV, max 10 mg] was administered for PONV prophylaxis and postoperative pain control (AAO-HNS 2019 strong recommendation). 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 [cold steel dissection / 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 / bipolar / ties]. 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.] Post-operative analgesia: scheduled ibuprofen and acetaminophen alternating per AAO-HNS guideline. Codeine was NOT prescribed (contraindicated in children under 12 and post-tonsillectomy in all ages per FDA black box warning). Return precautions for bleeding reviewed.

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 for OSA. No distinct CPT code — bill with the standard tonsillectomy codes (42825 under 12, 42826 age 12+). Note that CPT 42836 is adenoidectomy (secondary/regrowth), not tonsillotomy. Document partial removal, residual tonsillar tissue retained, and capsule preserved.

Charting Tips
  • Document Paradise criteria for recurrent tonsillitis cases: episode count and qualifying features (temp >38.3C, lymphadenopathy, exudate, or positive GABHS) for each episode. AAO-HNS 2019 CPG requires medical necessity documentation. Without this, payers will deny coverage regardless of symptoms.
  • State age explicitly. Drives CPT code selection (under 12 vs. 12 and older). Also determines PSG requirements: AAO-HNS 2019 recommends PSG before T&A for OSA in children under 2 years, obesity, Down syndrome, craniofacial or neuromuscular disorders, sickle cell, or mucopolysaccharidoses. PSG is not required for otherwise healthy children with clinically apparent OSA/SDB.
  • Document dissection technique: cold steel, electrocautery, or coblation. Cold dissection and coblation are associated with less postoperative pain than monopolar electrocautery. Technique affects post-op pain outcomes but not CPT code selection.
  • Adenoidectomy visualization method (mirror vs. nasal endoscope). Document Eustachian tube orifice preservation.
  • Hemostasis method at completion. No active bleeding confirmed before extubation.
  • Specimen to pathology: NOT required for symmetric tonsils removed for benign indications (recurrent tonsillitis, OSA). Required for asymmetric or unilateral tonsillar enlargement, suspected malignancy, constitutional symptoms (weight loss, night sweats, lymphadenopathy), or immunocompromised patients (Erdag et al., low yield in routine benign cases).
  • Pain management: ibuprofen and acetaminophen are recommended post-operatively (AAO-HNS 2019 Grade A). Codeine is contraindicated post-tonsillectomy in all ages (FDA black box). Do NOT prescribe codeine or tramadol.
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, 2.58 wRVU) or 42831 (12 and older, 2.74 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.

General coding reference. Verify with your institution’s billing department before submitting claims.

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