Tonsillectomy and adenoidectomy; age under 12 years

CPT 42820 is the billing code for "Tonsillectomy and adenoidectomy; age under 12 years". Tonsillectomy and adenoidectomy in patient under 12 years of age

Medicare pays approximately $287.56 for CPT 42820 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.

CPT 42820 has a total RVU of 9.86, broken down as: Work RVU 4.50, Practice Expense RVU 5.00, and Malpractice RVU 0.36. RVUs (Relative Value Units) determine Medicare reimbursement rates.

Key documentation requirements for CPT 42820 include: Age of patient documented (<12); Tonsillectomy and adenoidectomy documented; Method of removal documented; Patient response to procedure. Missing or incomplete documentation is a leading cause of claim denials for this code.

Bundling considerations for CPT 42820: Includes tonsillectomy and adenoidectomy. Age <12 only Use an NCCI bundling checker to verify specific code combinations before billing.

Common modifiers for CPT 42820 include: 59 (Distinct procedural service when multiple procedures performed), 50 (Bilateral procedure). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.

The typical time requirement for CPT 42820 is Typically 30-45 minutes. Time-based codes require documentation of the actual time spent providing the service.