How To Use CPT Code 42820

CPT 42820 refers to a tonsillectomy and adenoidectomy procedure performed on a patient younger than 12 years old. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 42820 procedures.

1. What is CPT 42820?

CPT 42820 is a medical code used to describe a tonsillectomy and adenoidectomy procedure performed on a patient younger than 12 years old. This code is used by medical coders and billers to accurately document and bill for this specific surgical procedure.

2. 42820 CPT code description

The official description of CPT code 42820 is: “Tonsillectomy and adenoidectomy; younger than age 12.”

3. Procedure

The 42820 procedure involves the following steps:

  1. Administration of anesthesia to the patient.
  2. Preparation and draping of the patient in a sterile fashion.
  3. Insertion of a mouth gag to inspect and grasp the tonsils with a curved clamp and retract them.
  4. Making a mucosal incision in the medial aspect of the tonsillar pillar using a blade (e.g., no. 12).
  5. Isolation of the tonsillar capsules with sharp and blunt dissection.
  6. Removal of adenoid tissues using an adenoid curette (such as a St. Claire Thompson curette) or biting forceps, confirmed with a laryngeal mirror.
  7. Control of bleeding with a snare or electrocautery.

A tonsillectomy can also be performed using cryogenic (freezing), laser, and electrocautery methods.

4. Qualifying circumstances

Patients eligible to receive CPT code 42820 services are those younger than 12 years old who require a tonsillectomy and adenoidectomy due to medical conditions such as recurrent tonsillitis, obstructive sleep apnea, or other related issues. The decision to perform this procedure is typically based on the patient’s medical history, physical examination, and the severity of their symptoms.

5. When to use CPT code 42820

It is appropriate to bill the 42820 CPT code when a tonsillectomy and adenoidectomy procedure is performed on a patient younger than 12 years old. This code should be used to accurately document and bill for the specific surgical procedure, ensuring proper reimbursement for the healthcare provider.

6. Documentation requirements

To support a claim for CPT 42820, the following information should be documented:

  • Patient’s age at the time of the procedure.
  • Medical necessity for the tonsillectomy and adenoidectomy, including the patient’s medical history, physical examination, and symptoms.
  • A detailed description of the surgical procedure, including the steps performed and any additional methods used (e.g., cryogenic, laser, or electrocautery).
  • Postoperative care instructions and follow-up appointments.

7. Billing guidelines

When billing for CPT code 42820, it is important to follow the specific guidelines and rules set by the payer. Some tips for billing this code include:

  • Ensure that the patient’s age is accurately documented, as this code is only applicable for patients younger than 12 years old.
  • Do not unbundle the tonsillectomy and adenoidectomy codes, as insurers consider this unbundling.
  • Be aware of any payer-specific policies regarding the use of cryogenic, laser, or electrocautery methods for tonsillectomy.

8. Historical information

CPT 42820 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2007, with the previous descriptor being “Tonsillectomy and adenoidectomy; under age 12.”

9. Similar codes to CPT 42820

Five similar codes to CPT 42820 and how they differentiate are:

  1. CPT 42821: Tonsillectomy and adenoidectomy for patients 12 years of age or older.
  2. CPT 42825: Primary or secondary tonsillectomy without adenoidectomy for patients younger than 12 years old.
  3. CPT 42826: Primary or secondary tonsillectomy without adenoidectomy for patients 12 years of age or older.
  4. CPT 42830: Primary adenoidectomy without tonsillectomy for patients younger than 12 years old.
  5. CPT 42831: Primary adenoidectomy without tonsillectomy for patients 12 years of age or older.

10. Examples

Here are 10 detailed examples of CPT code 42820 procedures:

  1. A 6-year-old patient with recurrent tonsillitis undergoes a tonsillectomy and adenoidectomy.
  2. An 8-year-old patient with obstructive sleep apnea due to enlarged tonsils and adenoids has a tonsillectomy and adenoidectomy.
  3. A 10-year-old patient with a history of frequent throat infections undergoes a tonsillectomy and adenoidectomy.
  4. A 5-year-old patient with difficulty swallowing due to enlarged tonsils and adenoids has a tonsillectomy and adenoidectomy.
  5. A 7-year-old patient with chronic tonsillitis and adenoiditis undergoes a tonsillectomy and adenoidectomy.
  6. An 11-year-old patient with a history of snoring and sleep disturbances due to enlarged tonsils and adenoids has a tonsillectomy and adenoidectomy.
  7. A 9-year-old patient with recurrent episodes of tonsillitis and adenoiditis undergoes a tonsillectomy and adenoidectomy.
  8. A 4-year-old patient with a history of frequent upper respiratory infections and enlarged tonsils and adenoids has a tonsillectomy and adenoidectomy.
  9. A 6-year-old patient with a history of recurrent ear infections and enlarged adenoids undergoes a tonsillectomy and adenoidectomy.
  10. An 8-year-old patient with a history of persistent sore throat and difficulty breathing due to enlarged tonsils and adenoids has a tonsillectomy and adenoidectomy.

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