How To Use CPT Code 42826

CPT 42826 refers to a tonsillectomy procedure performed on patients aged 12 or older. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 42826.

1. What is CPT 42826?

CPT 42826 is a medical code used to describe a tonsillectomy procedure performed on patients who are 12 years of age or older. This code is used by medical coders and billers to accurately document and bill for this specific procedure.

2. 42826 CPT code description

The official description of CPT code 42826 is: “Tonsillectomy, primary or secondary; age 12 or over.”

3. Procedure

The 42826 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. Resection of the tonsils off the tonsillar capsules.
  7. Control of bleeding with a snare (Eve’s snare) or electrocautery.

A tonsillectomy can also be performed by cryogenic, laser, and electrocautery methods.

4. Qualifying circumstances

Patients eligible to receive CPT code 42826 services are those who are 12 years of age or older and require a primary or secondary tonsillectomy procedure. This may include patients with recurrent tonsillitis, sleep apnea, or other medical conditions that necessitate the removal of the tonsils.

5. When to use CPT code 42826

It is appropriate to bill the 42826 CPT code when a tonsillectomy procedure is performed on a patient who is 12 years of age or older. This code should be used for primary, recurrent, or secondary tonsillectomy procedures in this age group.

6. Documentation requirements

To support a claim for CPT 42826, the following information needs to be documented:

  • Patient’s age at the time of the procedure.
  • Medical necessity for the tonsillectomy, including the patient’s diagnosis and relevant medical history.
  • Detailed description of the procedure performed, including the method used (e.g., cryogenic, laser, or electrocautery).
  • Any complications or additional procedures performed during the tonsillectomy.
  • Postoperative care instructions and follow-up plan.

7. Billing guidelines

When billing for CPT code 42826, it is important to follow the appropriate guidelines and rules. Some tips and codes that apply to CPT code 42826 include:

  • Ensure that the patient’s age is accurately documented, as this code is specific to patients aged 12 or older.
  • Verify that the medical necessity for the tonsillectomy is clearly documented in the patient’s medical record.
  • Be aware of any payer-specific policies regarding the use of laser tonsillectomy, as some insurers may have different requirements for billing this procedure.

8. Historical information

CPT 42826 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to this code since its addition.

9. Similar codes to CPT 42826

Five similar codes to CPT 42826 and how they differentiate from CPT 42826 are:

  • CPT 42825: Tonsillectomy for patients younger than 12 years of age.
  • CPT 42820: Tonsillectomy and adenoidectomy combined for patients younger than 12 years of age.
  • CPT 42821: Tonsillectomy and adenoidectomy combined for patients aged 12 or older.
  • CPT 42830: Primary adenoidectomy without tonsillectomy for patients younger than 12 years of age.
  • CPT 42831: Primary adenoidectomy without tonsillectomy for patients aged 12 or older.

10. Examples

Here are 10 detailed examples of CPT code 42826 procedures:

  1. A 14-year-old patient with recurrent tonsillitis undergoes a primary tonsillectomy using electrocautery.
  2. A 16-year-old patient with obstructive sleep apnea has a secondary tonsillectomy performed using a laser technique.
  3. A 12-year-old patient with a history of peritonsillar abscesses undergoes a primary tonsillectomy using the traditional cold knife method.
  4. A 17-year-old patient with chronic tonsillitis has a primary tonsillectomy performed using cryogenic technique.
  5. A 15-year-old patient with a history of recurrent strep throat infections undergoes a secondary tonsillectomy using electrocautery.
  6. A 13-year-old patient with sleep-disordered breathing has a primary tonsillectomy performed using a laser technique.
  7. A 19-year-old patient with a history of tonsil stones undergoes a primary tonsillectomy using the traditional cold knife method.
  8. A 20-year-old patient with chronic tonsillitis has a secondary tonsillectomy performed using cryogenic technique.
  9. A 18-year-old patient with a history of recurrent tonsillitis undergoes a primary tonsillectomy using electrocautery.
  10. A 21-year-old patient with obstructive sleep apnea has a primary tonsillectomy performed using a laser technique.

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