Tonsillectomy CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Examples

Tonsillectomy CPT code(s) 42820, 42821, 42825, 42826 bills for service when the Physician performs a Tonsillectomy and adenoidectomy or a primary or secondary Tonsillectomy under the age of 12 or over 12 years.

Tonsillectomy CPT Code Description 

The following are the reasons why the Physician performs Tonsillectomy:

The patient may suffer from bleeding in the tonsils,

Recurring, severe, or chronic tonsillitis,

The patient may have giant tonsils or complications,

Other related diseases to tonsils.

The Physician removes the tonsils. Since the primary operation, the Tonsillectomy can be the first patient’s surgery or a secondary procedure to remove tonsil regrowth. The Physician accesses the tonsils in an intraoral approach. 

First, the Physician removes the tonsils by grasping the tonsil clamp with a tonsil clamp, dissecting the capsule, and removing the tonsils. 

Bleeding vessels are clamped and tied—the Physician may control bleeding using silver nitrate and gauze packing.

 Alternate surgical techniques for a tonsillectomy include electrocautery, laser, and cryogenic surgery. Report 42825 if the patient is under 12 years; for patients 12 years or older, report 42826.

CPT 42820

Tonsillectomy CPT code 42820 bills for service when the Physician performs a Tonsillectomy and adenoidectomy; younger than age 12.

CPT 42821

CPT 42821 bills for service when the Physician performs a Tonsillectomy and adenoidectomy; age 12 or over.

CPT 42825

Tonsillectomy CPT code 42825 bills for service when the Physician performs a Tonsillectomy, primary or secondary; younger than age 12.

CPT 42826

CPT 42826 bills for service when the Physician performs a Tonsillectomy, primary or secondary; age 12 or over.

Tonsillectomy CPT Code Reimbursement    

 A maximum of one unit can be a bill on the same service date of Tonsillectomy CPT code(s) 42820, 42821, 42825, or 42826. In contrast, the Two units allow documentation supporting the service’s medical necessity.   

The cost and RUVS of CPT 42820 are $322.88 and 9.33001 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 42820 are $322.88 and 9.33001 when performed in the non-facility. 

The cost and RUVS of CPT 42821 are $337.57 and 9.75455 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 42821 are $337.57 and 9.75455 when performed in the non-facility.

The cost and RUVS of Tonsillectomy CPT code 42825 are $300.20 and 8.67473 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 42825 are $300.20 and 8.67473 when performed in the non-facility.

The cost and RUVS of CPT 42826 are $285.01 and 8.23585 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 42826 are $285.01 and 8.23585 when performed in the non-facility.

Tonsillectomy CPT Code Modifiers 

The following are the list modifiers applicable with Tonsillectomy CPT code(s) 42820, 42821, 42825, 42826:   

• 22, 23, 47, 51, 52, 53, 54, 55, 56, 58, 59, 62, 63, 76, 77, 78, 79, 80, 81 82, 99, , AS, CC, CR, ET, EY, GA, GC, GK, GR, GU, GY, GZ, KX, Q5, Q6, QJ, SG, TC, XR, XP, XU, XS, AI, AQ, AR.     

Modifier 47 applies to CPT 42820, 42821, 42825, and 42826 when the surgeon administers general or regional anesthesia to the patient. It is not appropriate to report modifier 47 with anesthesia procedures.  

Modifier 76 is appropriate with CPT 42820, 42821, 42825, and 42826 when a similar service operates by the identical Physician on the same day.   

Modifier 54 is applicable with Tonsillectomy CPT code(s) 42820, 42821, 42825, and 42826 when the Physician provides surgical care only. In contrast, Modifiers 55 and 56 attach to CPT 42820, 42821, 42825, and 42826 when the Physician performs post-management and pre-operative care only.   

Modifier 76 is applicable with CPT 42820, 42821, 42825, and 42826 when a similar service performs by a different Physician on the same service date.   

Modifier 59 is applicable with CPT 42820, 42821, 42825, and 42826  when a Distinct service performs by the Physician and bundled with another procedure on the same date.     

 Modifier X {E, P, S, U} is applicable instead of Modifier 59 with CPT 42820, 42821, 42825, and 42826   when service bills to Medicare insurance. It divides the modifier into four parts for further specification of the procedure.   

Modifier 53 will be reported with CPT 42820, 42821, 42825, and 42826 if an unsuccessful attempt for an inguinal hernia repair makes due to unavoidable circumstances like allergic reactions to the substance.   

Modifier 22 applies to Tonsillectomy CPT code(s) 42820, 42821, 42825, and 42826 when services perform longer than usual and take extra resources.   

Modifier 23 is applicable with CPT 42820, 42821, 42825, and 42826 when general or local anesthesia administers by the Physician and routinely does not require during the procedure.   

Modifier 52 applies when the Physician does not complete the inguinal hernia repair service and terminates due to unavoidable circumstances.   

If physicians believe that Medicare will deny such service, reporting with a GA modifier is appropriate. The beneficiary must sign an Advance Beneficiary Notification (ABN), and CPT 42820, 42821, 42825, and 42826 must apply the GA modifier to that service.

Tonsillectomy CPT Code Billing Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.   

C09.8, C09.9, C79.89, D10.4, D37.05, D49.0, J03.01, J03.81, J03.91, J35.01, J35.1, J35.8, J36

The provider must submit the document to the insurance before the procedure, and the reasons should be strep infection or other related diseases.

If the Physician qualifies to perform the procedure, he will submit the information to the insurance accordingly.

If the condition is pre-existing, this procedure may not be covered or may only cover partially until the pre-existing condition period of the plan benefit is met—postoperative complications (e.g., control of postoperative bleeding report separately.

 Most payers consider tonsillectomy and adenoidectomy codes to be bilateral. For Tonsillectomy, primary or secondary, see 42825 and 42826. For adenoidectomy, primary, see 42830 and 42831; secondary, see 42835 and 42836.

Tonsillectomy CPT code(s) 42820, 42821, 42825, or 42826 has 90 days global period. If any Evaluation and management (E/M) service perform in conjunction with CPT code 42820, 42821, 42825, 42826, modifier 24 will report with E/M service for an unrelated condition. 

Suppose the E/M visit is for postoperative care of a prior surgical procedure if the patient sees for an unrelated condition on the exact procedure date. In that case, it is not appropriate to report the E/M code with 42820, 42821, 42825, and 42826 separately during the global period time. While modifier 25 will be applicable with CPT codes 42820, 42821, 42825, and 42826. 

Tonsillectomy CPT Code Examples

The following are the example when Tonsillectomy CPT code(s) 42820, 42821, 42825, and 42826 bills:

Example 1

A 25-year-old female presents with severe tonsilitis. The patient also suffered from bleeding for six days. She did have other symptoms of itching in the throat and pain.

The physical exam revealed swelling in the neck and throat region. The Physician ordered an X-ray and MRI of the neck. He is currently taking antibiotics for tonsillitis, but no improvements.

 It shows no skin infections around the other body parts. The patient denies any other symptoms such as headache, numbness, urinary problems, nausea, vomiting, and shortness of breath. 

The Physician advises Tonsillectomy to prevent infection in the future and prescribes mediation. The insurance may not reimburse the reason for this encounter as not tonsilitis or a severe condition.

He schedules an appointment for next week and discusses the pros and cons of the procedure.

Example 2

Medical Specialty:

ENT – Otolaryngology

Sample Name: Tonsillectomy

Description: Tonsillectomy. Tonsillitis. McIvor’s mouth gag appropriates in the oral cavity, and a tongue depressor was applied.

(Medical Transcription Sample Report)

Pre-Operative  Indication: 

Tonsillitis

Postoperative diagnosis: 

Tonsillitis

Procedure description:

Tonsillectomy

ANESTHESIA: General anesthesia via endotracheal

PROCEDURE Description: 

The patient took to the operating room and prepped and draped in the usual fashion. After induction of general endotracheal anesthesia, the McIvor mouth gag incorporates into the oral cavity, and a tongue depressor applies.

Two #12-French red rubber Robinson catheters identified 1 in each nasal passage are brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction. The nasopharynx inspects with the laryngeal mirror.

The Physician then focuses on the right tonsil. The anterior tonsillar pillar infiltrates with 3.6 CC of 1% Xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar.

 The plica semilunaris incise with the Metzenbaum scissors. The tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied using the Metzenbaum scissors and the Fisher knife.

The anterior tonsillar pillar incises with the #12 knife blade. The right tonsil was grasped with the tenaculum and retracted from its fossa.

 The tonsil removes from the fossa, and the fossa pack with a cherry gauze sponge. By a similar procedure, the opposite Tonsillectomy performs, and the fossa was packed.

Attention was re-directed to the right tonsil. The pack removes and bleeding control with the suction Bovie unit. After removing the bags, bleeding was similarly present in the left tonsillar fossa and the nasopharynx. 

The Physician removed the catheters, and the nasal passages and oropharynx were suctioned free of debris. The procedure terminates by the Physician.

The patient endured the procedure perfectly and left the operating room in good condition.