42826

😷 CPT Code 42826 - Tonsillectomy and Adenoidectomy; Under Age 12

Code Description

CPT 42826 - Tonsillectomy and adenoidectomy; under age 12

This code represents the combined surgical removal of both the tonsils (palatine tonsils) and the adenoids (pharyngeal tonsils) in a patient who is under 12 years of age at the time of surgery. This is one of the most common pediatric Otolaryngology procedures.

Critical Age Distinction:

42826: Patient is under 12 years old.
42825: Patient is 12 years of age or older.

Code Tree/Hierarchy

CPT Code Structure
└── Surgery (10000-69999)
    └── Digestive System (40000-49999)
        └── Oropharynx and Adenoids (42800-42999)
            └── Tonsils and Adenoids (42820-42835)
                ├── 42820 - Tonsillectomy and adenoidectomy; under age 12 (Deleted/Replaced)
                ├── 42821 - Tonsillectomy and adenoidectomy; age 12 or over (Deleted/Replaced)
                ├── 42825 - Tonsillectomy and adenoidectomy; age 12 or over
                ├── 42826 - Tonsillectomy and adenoidectomy; under age 12
                ├── 42830 - Tonsillectomy, primary or secondary; under age 12
                ├── 42831 - Tonsillectomy, primary or secondary; age 12 or over
                ├── 42835 - Tonsillectomy, primary or secondary; age 12 or over
                └── 42836 - Excision of lingual tonsil

Common Primary Diagnoses

ICD-10-CM Code	Description
J35.01	Chronic tonsillitis
J35.02	Chronic adenoiditis
J35.03	Chronic tonsillitis and adenoiditis
J35.1	Hypertrophy of tonsils
J35.2	Hypertrophy of adenoids
J35.3	Hypertrophy of tonsils with hypertrophy of adenoids
G47.33	Obstructive sleep apnea (adult or pediatric)
P28.89	Other specified respiratory conditions originating in the perinatal period
J35.8	Other chronic diseases of tonsils and adenoids
J35.9	Chronic disease of tonsils and adenoids, unspecified
J03.90	Acute tonsillitis, unspecified
J03.91	Acute tonsillitis, unspecified (Recurrent)

External Cause Codes (Reference: icd10cm_eindex_2025.pdf)

Note: Tonsillectomy and adenoidectomy are typically elective procedures for chronic conditions or sleep apnea. External cause codes are generally not assigned unless the condition resulted from an injury (e.g., trauma to the oropharynx requiring removal). If applicable based on the uploaded External Cause Index:

Category	Code Example	Description from Index
Place of Occurrence (Y92)	Y92.239	Hospital (unspecified)
	Y92.009	Private residence
	Y92.531	Dentist office
Activity (Y93)	Y93.89	Activity specified NEC
	Y93.01	Walking
	Y93.61	Football (American)
Status (Y99)	Y99.0	Civilian activity done for income or pay
	Y99.8	Leisure activity
	Y99.1	Military activity

Usage Note: Assign external cause codes only if the medical record documents an external cause (e.g., trauma) leading to the necessity of the procedure. For routine chronic tonsillitis or sleep apnea, external cause codes are not applicable.

Includes

tonsillectomy - Removal of both palatine tonsils
Adenoidectomy - Removal of the pharyngeal tonsils (adenoids)
Patient Age - Must be under 12 years old on date of service
Anesthesia - General anesthesia is typically required
Hemostasis - Control of bleeding during procedure
Immediate Post-op Care - Recovery room care included in global period

Excludes

Code	Description	Reason
42825	tonsillectomy and adenoidectomy; age 12 or over	Wrong age group
42830	Tonsillectomy; under age 12	Adenoids not removed
42831	Tonsillectomy; age 12 or over	Adenoids not removed, wrong age
42835	Excision of tonsil, lingual	Different anatomical site
42836	Excision of lingual tonsil	Different anatomical site
42840	Excision of peritonsillar abscess	Different procedure (I&D)
42842	Excision of peritonsillar abscess	Different procedure (I&D)
42850	Removal of foreign body, pharynx	Different procedure
42860	Suture of pharynx	Different procedure
42870	Pharyngoplasty	Different procedure

Assistant Surgeon Information

Payer Type	Assistant Payable	Typical Reimbursement
Medicare	No (Status Indicator 0)	$0.00
Commercial	Varies by contract	Rarely allowed
Medicaid	Varies by state	Rarely allowed

Note: Medicare and most payers consider this a routine procedure that does not require an assistant surgeon. Billing with modifier 80/81/82 will likely result in denial.

Work RVU Breakdown (2025 Medicare Physician Fee Schedule)

Component	RVU Value	Description
Work RVU	5.36	Physician work effort
Practice Expense RVU	2.50	Facility/equipment costs
Malpractice RVU	0.52	Liability insurance costs
Total RVU (Non-Facility)	10.50	Office-based setting (Rare for T&A)
Total RVU (Facility)	8.38	Hospital/ASC setting (Common)

Note: RVU values may vary by geographic location due to GPCI adjustments. T&A is predominantly performed in ASC or Hospital Outpatient settings.

MS-DRG Information (Inpatient Procedures)

Important: Tonsillectomy and adenoidectomy are overwhelmingly performed as outpatient or ambulatory surgery center (ASC) procedures. Inpatient admission is rare and usually requires significant comorbidities (e.g., severe sleep apnea with desaturation, bleeding disorders, age < 3 years with comorbidities).

If performed in an inpatient setting, 42826 may map to the following MS-DRGs:

MS-DRG	Description	Relative Weight (Approx.)
068	Other Ear, Nose, Mouth, Throat Procedures	1.15
067	Other Ear, Nose, Mouth, Throat Diagnoses	0.95
064	Head & Neck Malignancy with Major OR Procedure	2.85 (If malignancy present)

CC/MCC Considerations:

MCC: Severe malnutrition, respiratory failure, tracheostomy
CC: Asthma, pneumonia, dehydration, anemia

Global Period

Period	Days	Services Included
Pre-operative	1 day	Day before surgery
Intra-operative	0 days	Day of surgery
Post-operative	10 days	10 days following surgery
Total Global	10 days	All related E/M services included

Services NOT included in global period:

Treatment for unrelated conditions
Return to OR for complications (use modifier 78)
Decision for surgery (use modifier 57 if within global of another procedure)
Staged procedures (use modifier 58)

Modifiers

Modifier	Description	When to Use
-50	Bilateral procedure	Not applicable (Code includes both tonsils)
-51	Multiple procedures	When additional distinct procedures performed
-52	Reduced services	Procedure partially reduced
-53	Discontinued procedure	Procedure stopped due to patient condition
-57	Decision for surgery	E/M on day of surgery leading to decision
-58	Staged procedure	Planned return to OR during global period
-59	Distinct procedural service	Separate from other same-day procedures
-76	Repeat procedure by same physician	Same procedure repeated
-77	Repeat procedure by different physician	Same procedure by different surgeon
-78	Return to OR for complication	Unplanned return during global period (e.g., bleeding)
-79	Unrelated procedure during global	Different procedure during global period
-LT	Left side	Not applicable (Midline/Paired included)
-RT	Right side	Not applicable (Midline/Paired included)
-23	Unusual anesthesia	If general anesthesia required due to condition
-47	Anesthesia by surgeon	If surgeon provides anesthesia (Rare)

Coding Examples

Example 1: Routine Pediatric T&A for Sleep Apnea

CPT: 42826
ICD-10-CM: J35.3 (Hypertrophy of tonsils with hypertrophy of adenoids)
ICD-10-CM: G47.33 (Obstructive sleep apnea)
Description: 7-year-old patient underwent tonsillectomy and adenoidectomy 
for obstructive sleep apnea and tonsillar hypertrophy. Patient age verified 
as under 12. Procedure completed without complication.

Example 2: Recurrent Tonsillitis

CPT: 42826
ICD-10-CM: J35.03 (Chronic tonsillitis and adenoiditis)
Description: 10-year-old patient with history of 7 episodes of tonsillitis 
in past year. Underwent T&A. Pathology confirmed chronic inflammation.

Example 3: Return to OR for Hemorrhage (Within Global)

CPT: 42826 (Initial)
CPT: 42826-78 (Return to OR)
ICD-10-CM: J35.03, T81.0XXA (Hemorrhage following procedure)
Description: Patient returned to OR on post-op day 5 for control of 
post-tonsillectomy hemorrhage. Modifier 78 appended.

Example 4: Age 12 or Older (Incorrect Code Usage)

CPT: 42825 (Correct code for age 12+)
ICD-10-CM: J35.3
Description: Patient turned 12 years old 1 month prior to surgery. 
Code 42826 would be denied; 42825 is correct.

Example 5: Trauma Context (Using External Cause Codes)

CPT: 42826
ICD-10-CM: S09.8XXA (Other specified injuries of head)
External Cause: Y92.239 (Hospital), Y93.61 (Football), Y99.8 (Leisure)
Description: Rare case where traumatic injury to oropharynx necessitated 
removal of tonsils/adenoids. External cause codes assigned per 
External Cause Index guidelines.

Documentation Requirements

Operative Report Must Include:

Preoperative Diagnosis
Postoperative Diagnosis
Procedure Performed (Tonsillectomy and Adenoidectomy)
Patient Age - CRITICAL (Must document date of birth or age)
Indications for Surgery (Sleep apnea, recurrent infection, etc.)
Technique (Electrocautery, coblation, cold steel, etc.)
Tonsil Removal - Confirmation both tonsils removed
Adenoid Removal - Confirmation adenoids removed
Hemostasis - Method and confirmation of stability
Complications (if any)
Specimen Sent to Pathology (Routine for tonsils)

Key Phrases to Document:

“Patient is [X] years old” (Must be under 12)
“Bilateral tonsillectomy performed”
“Adenoidectomy performed”
“Hemostasis achieved”
“Specimens sent to pathology”
“Patient tolerated procedure well”

Medical Necessity

Indications for 42826:

Obstructive Sleep Apnea (OSA) - Documented by sleep study or clinical evaluation
Recurrent Tonsillitis - Paradise Criteria (7 episodes in 1 year, 5/year for 2 years, 3/year for 3 years)
Peritonsillar Abscess - History of recurrent abscess
Airway Obstruction - Due to hypertrophy
Suspected Malignancy - Biopsy/removal of suspicious tissue
Chronic Infection - Unresponsive to antibiotics

Contraindications:

Cleft Palate - Risk of velopharyngeal insufficiency (relative contraindication)
Bleeding Disorders - Uncontrolled coagulopathy
Acute Infection - Sometimes delayed until acute phase resolves
Medically Unstable - Cannot tolerate anesthesia

Common Denial Reasons

Denial Code	Reason	Resolution
CO-50	Medical necessity	Provide sleep study or infection records
CO-16	Missing information	Submit operative report with age
CO-22	Billing/coding error	Verify patient age matches code (42826 vs 42825)
CO-97	Bundled service	Verify procedure not included in global
CO-109	Not covered by payer	Check patient benefits for T&A coverage

Compliance Considerations

Age Verification - The most common audit trigger. Ensure DOB matches code selection (42826 vs 42825).
Medical Necessity - Payers often require documentation of Paradise Criteria or sleep study results.
Assistant Surgeon - Do not bill assistant surgeon unless specific payer policy allows (rare).
Global Period - Do not bill post-op visits for routine care within 10 days.
Pathology - Ensure tonsil specimens are sent and pathology report matches diagnosis.
External Causes - Only assign if trauma is documented per External Cause Index guidelines.

CPT	Description	Relationship
42825	T&A; age 12 or over	Age alternative
42830	Tonsillectomy; under age 12	Adenoids not removed
42831	Tonsillectomy; age 12 or over	Adenoids not removed
42835	Excision of lingual tonsil	Different site
42840	Incision of peritonsillar abscess	Different procedure
42842	Excision of peritonsillar abscess	Different procedure
42850	Removal of foreign body, pharynx	Different procedure
31575	Laryngoscopy with nerve monitoring	If performed separately

Clinical Pearls

Bleeding Risk - Primary hemorrhage (within 24 hours) and secondary hemorrhage (5-10 days post-op) are key risks.
Pain Management - Codeine is contraindicated in children post-T&A due to respiratory depression risk.
Hydration - Post-op dehydration is a common reason for readmission.
Velopharyngeal Insufficiency - Risk increases in patients with submucous cleft palate.
Sleep Study - Many payers require polysomnography for OSA indication in children.
Age Cutoff - Patient age on date of service determines code selection, not age at consultation.

Quick Reference Card

┌─────────────────────────────────────────────────────────┐
│  CPT 42826 - T&A Under Age 12                           │
├─────────────────────────────────────────────────────────┤
│  Global Period: 10 days                                 │
│  Assistant Allowed: No (Medicare)                       │
│  Bilateral: Inherent (No Modifier 50)                   │
│  wRVU: 5.36                                             │
│  Key Documentation: Patient Age (Under 12)              │
│  Common ICD-10: J35.3, G47.33, J35.03                   │
│  MS-DRG: 068 (Rarely Inpatient)                         │
│  Ext. Cause: Y92, Y93, Y99 (If trauma)                  │
└─────────────────────────────────────────────────────────┘

Last Updated: February 2026 Code Status: Active Next Review: January 2027

Explorer