Tonsillectomy and adenoidectomy; age 12 years or over

CPT 42821 is the billing code for "Tonsillectomy and adenoidectomy; age 12 years or over". Tonsillectomy and adenoidectomy in patient age 12 years or older

Medicare pays approximately $299.85 for CPT 42821 (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 42821 has a total RVU of 10.90, broken down as: Work RVU 5.00, Practice Expense RVU 5.50, and Malpractice RVU 0.40. RVUs (Relative Value Units) determine Medicare reimbursement rates.

Key documentation requirements for CPT 42821 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 42821: Includes tonsillectomy and adenoidectomy. Age 12+ only Use an NCCI bundling checker to verify specific code combinations before billing.

Common modifiers for CPT 42821 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 42821 is Typically 45-60 minutes. Time-based codes require documentation of the actual time spent providing the service.