Tonsillectomy, primary or secondary; age under 12 years
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Tonsillectomy medical necessity not established - age or frequency criteria
Common42826 (tonsillectomy primary, age 12 or over) requires documented medical necessity per clinical guidelines. Denied when: frequency criteria not met (fewer than 7 episodes in 1 year, 5/year for 2 years, or 3/year for 3 years), conservative treatment not attempted, or indication doesn't meet guidelines (sleep apnea without documented severity, chronic tonsillitis without adequate antibiotic trials).
Common Causes
- • Recurrent tonsillitis but doesn't meet frequency criteria - 3-4 episodes/year insufficient
- • Sleep apnea indication but no sleep study documenting severity or obstruction
- • Conservative treatment not documented - need 6-12 months antibiotics, observation
Resolution Strategy
Document meeting Paradise criteria: 'Patient age 28 with recurrent acute tonsillitis. Past year: 8 documented episodes requiring antibiotics (dates: 1/15, 3/2, 4/18, 6/3, 7/22, 9/8, 10/14, 11/30). Each episode: fever >38.3°C, tonsillar exudate, cervical adenopathy, positive strep on 5 occasions. Failed conservative management with prophylactic antibiotics (amoxicillin 250mg daily x 3 months) without reduction in frequency. Meets Paradise criteria (>7 episodes in 1 year). Tonsillectomy medically necessary.' Alternative for sleep apnea: 'Polysomnography shows severe OSA (AHI 42, lowest O2 sat 78%) with 3+ tonsillar hypertrophy causing obstruction. Failed CPAP trial. Tonsillectomy indicated per AAO-HNS guidelines.' Must document: episode frequency with dates, antibiotic treatment for each, strep testing, conservative treatment attempted, how meets clinical criteria. Cannot appeal if criteria not met.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Tonsillectomy only (primary or secondary) in patient under 12 years of age
Common Scenarios
Documentation Requirements
- Age of patient documented (<12)
- Tonsillectomy documented
- Primary or secondary documented
- Method of removal documented
- Patient response to procedure
Coding Guidelines
Common Modifiers
Bundling Rules
- Tonsillectomy only
- Primary or secondary
- Age <12 only
- Includes general anesthesia
Exclusions
- Do not bill if age 12+ (use age 12+ codes)
- Do not bill with adenoidectomy codes
Coding Notes
Clinical scenarios
- Age of patient documented (<12)
- Tonsillectomy documented
- Primary or secondary documented
- Age of patient documented (<12)
- Tonsillectomy documented
- Primary or secondary documented
- Age of patient documented (<12)
- Tonsillectomy documented
- Primary or secondary documented
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Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
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Ask a QuestionFrequently Asked Questions
CPT 42826 is the billing code for "Tonsillectomy, primary or secondary; age under 12 years". Tonsillectomy only (primary or secondary) in patient under 12 years of age
Medicare pays approximately $252.95 for CPT 42826 (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 42826 has a total RVU of 7.78, broken down as: Work RVU 3.50, Practice Expense RVU 4.00, and Malpractice RVU 0.28. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 42826 is "Tonsillectomy medical necessity not established - age or frequency criteria". 42826 (tonsillectomy primary, age 12 or over) requires documented medical necessity per clinical guidelines. Denied when: frequency criteria not met (fewer than 7 episodes in 1 year, 5/year for 2 years, or 3/year for 3 years), conservative treatment not attempted, or indication doesn't meet guidelines (sleep apnea without documented severity, chronic tonsillitis without adequate antibiotic trials). Common causes include: Recurrent tonsillitis but doesn't meet frequency criteria - 3-4 episodes/year insufficient; Sleep apnea indication but no sleep study documenting severity or obstruction. Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 42826 include: Age of patient documented (<12); Tonsillectomy documented; Primary or secondary documented; Method of removal documented. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 42826: Tonsillectomy only. Primary or secondary Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 42826 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 42826 is Typically 20-30 minutes. Time-based codes require documentation of the actual time spent providing the service.