CPT Code 42821 | Description & Clinical Information
CPT 42821 describes the surgical procedure performed by a healthcare provider to remove both the tonsils and adenoids from a patient who is 12 years of age or older.
Official Description
The CPT book defines CPT code 42821 as: “Tonsillectomy and adenoidectomy; age 12 or over”.
Clinical Information
The procedure described by CPT code 42821 involves the removal of tonsils and/or adenoids. It is typically carried out under anesthesia, which allows for the patient to remain comfortably asleep throughout the operation. Once the anesthesia has taken effect, the patient is prepped and draped in a sterile fashion, which helps to reduce the risk of infection.
To begin the procedure, a mouth gag is inserted to help keep the patient’s mouth open. The tonsils are then inspected and grasped with a curved clamp and retracted, which helps to provide a clear view of the surgical site. Once the tonsils are properly exposed, a blade (such as a no. 12 blade) is used to make a mucosal incision in the medial aspect of the tonsillar pillar.
Following the incision, the tonsillar capsules are isolated with sharp and blunt dissection. This process involves separating the tonsil tissue from the surrounding area, which helps to ensure that the tonsils can be safely removed without causing damage to nearby structures.
For an adenoidectomy, the physician may use an adenoid curette (such as a St. Claire Thompson curette) or biting forceps to remove the adenoid tissues. The physician may also use a laryngeal mirror to confirm that all of the adenoid tissue has been removed.
Bleeding during the procedure is controlled with a snare (such as Eve’s snare) or electrocautery. These instruments help to seal off any blood vessels that may have been damaged during the surgery, which can help to minimize the risk of bleeding.
In addition to traditional surgical methods, tonsillectomies can also be performed using cryogenic, laser, and electrocautery methods. These approaches use specialized tools to freeze, burn, or cut away the tonsil tissues. While these methods can be effective, they may also have their own unique risks and complications.
Overall, the procedure described by CPT code 42821 is a commonly performed surgery that can help to alleviate symptoms of conditions such as sleep apnea, snoring, and chronic tonsillitis. As with any medical procedure, it is important to carefully consider the risks and benefits before undergoing the operation.
