ENT - Tonsillectomy & Adenoidectomy (T&A)

📋 The Rule (Quick Summary)

The Age Cutoff: T&A codes change strictly at Age 12. Under 12 = Higher RVU (more risk). 12 and Over = Lower RVU. Bundling: Control of bleeding (primary) is included. Do not bill for cautery during the initial surgery.

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💰 CPT Selection Logic

(Select based on: What was removed? + How old is the patient?)

1. Tonsils AND Adenoids (T&A):

• 42820: Under 12.
• 42821: Age 12 or older.

2. Tonsils ONLY:

• 42825: Under 12.
• 42826: Age 12 or older.

3. Adenoids ONLY:

• 42830: Under 12.
• 42831: Age 12 or older.

4. Post-Op Bleeding (Return to OR):

• 42960: Control oropharyngeal hemorrhage (Simple).
• 42962: Control with other methods (Secondary/Delayed bleed).

⚠️ Modifier Watch

Crucial modifiers for T&A:

• -50 (Bilateral): NO. These codes are inherently bilateral (“Tonsils” plural). Do not use -50.
• -52 (Reduced): Use if only one tonsil was removed (rare, but happens).
• -78 (Return to OR): Use if the patient bleeds 3 days later and has to go back for cautery (42962).

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🩺 Diagnosis & Medical Necessity

• Supported Diagnoses:
  • J35.01 (Chronic Tonsillitis)
  • G47.33 (Obstructive Sleep Apnea) - Very common indication for T&A in kids.
  • J35.3 (Hypertrophy of tonsils with adenoids)

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🚨 Documentation Alerts (Query Triggers)

If the note is missing this, I cannot code it:

1. “Adenoids Not Present”: If the surgeon went in to do T&A but found the adenoids had already atrophied (shrunk away) and didn’t remove them, you MUST downcode to “Tonsils Only.”
2. Technique: Coblation, cautery, and dissection are all included in the main code.