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    OpenPayerBilling CodesExcision and Destruction Procedures on the Pharynx, Adenoids, and TonsilsCPT cpt-42820-tonsillectomy-and-adenoidectomy-younger-than-12
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    CPT 42820: Tonsillectomy and Adenoidectomy, Patient Younger Than 12 Years

    Medicare pays $267 and commercial payers pay $1482 on average nationally for this procedure.

    CPT code 42820 describes a combined tonsillectomy and adenoidectomy procedure performed on a patient younger than 12 years old; this pediatric ENT surgical service is typically performed in an operating room or ambulatory surgical center and involves removal of the palatine tonsils and adenoids to treat obstructive or chronic tonsillar/adenoidal disease.

    For related coverage guidance, see recent payer policy updates: Dental Anesthesia Services, Anesthesia Services for Interventional Pain Management Procedures in an Adult, General Anesthesia and Conscious Sedation Services.

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    National Reimbursement Benchmarks

    Commercial averages sit well above Medicare for CPT 42820: Blue Cross Blue Shield and BUCA show notably higher mean rates, with BUCA averaging $1,481.80 versus Medicare’s mean of $266.60. UnitedHealth Group and Cigna also trend higher than Medicare, with UnitedHealth Group at $516.80 and Cigna at $495.60, indicating a clear split between commercial and Medicare pricing for this code.

    Dispersion (P75 minus P25) highlights where commercial pricing is most and least variable. Blue Cross Blue Shield has the widest interquartile spread at $2,016.50, driven by a high commercial ceiling, while Aetna displays one of the tightest spreads at $322.00. UnitedHealth Group ($315.50) and Cigna ($299.40) are moderately dispersed, and BUCA’s spread is $1,289.00, showing substantial variability among participating commercial contracts.

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    National Payer Mean Reimbursement Rates

    State Reimbursement Rates

    State: Alaska1 / 51

    Rate by payer

    Clinical & Coding Specifications

    Clinical Context

    A typical patient is a 6-year-old child referred by a pediatrician for recurrent throat infections and obstructive sleep-disordered breathing. The child has a history of frequent tonsillitis (multiple documented episodes over the past 12 months) and nasal obstruction with mouth-breathing, snoring, and daytime somnolence. Initial evaluation includes a focused ENT history and physical exam, confirmation of enlarged tonsils and adenoids on oral and nasal examination, and review of prior medical therapy. Preoperative assessment includes anesthesia clearance, airway evaluation, and informed consent with the parent or guardian. The procedure, 42820 (tonsillectomy and adenoidectomy; patient younger than 12 years), is performed in an outpatient surgical center or hospital operating room under general anesthesia. Typical workflow: pre-op nursing assessment, induction of general anesthesia with endotracheal intubation, oropharyngeal and nasopharyngeal inspection, removal of tonsillar tissue and adenoids using cold dissection or electrocautery techniques, hemostasis, emergence from anesthesia, post-anesthesia recovery monitoring, and discharge when PACU criteria are met. Postoperative instructions address pain control, hydration, activity restrictions, and indications for urgent return (excessive bleeding, dehydration, persistent fever). Payors commonly involved include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare for qualifying patients or dependents on Medicare plans for related coverage determinations.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure

    Related Modifiers

    9 rows

    ModifierDescriptionWhen to Use
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    59Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
    76Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…
    77Modifier 77 indicates that a previously performed procedure or service was legitimately repeated by a different physician or other qualified health care professional. The AMA’s CPT definition…- Use modifier 77 when a basic procedure or service already performed is repeated by a different physician or other qualified health care professional (for example, a second provider independently…
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
    50Modifier –50 (Bilateral Procedure) is appended to a CPT code when an identical procedure is performed on paired anatomical structures during the same operative session. The AMA states to add…- Use modifier -50 when the same CPT surgical, diagnostic, or radiology procedure is performed on paired anatomical structures (both sides of the body) during the same operative/session by the same…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207Y00000X
    207P00000X
    208000000X
    103TE1100X
    111NX0800X
    103TM1800X
    2086H0002X
    207K00000X

    Related Payer Policy Updates

    Specialty: Anesthesiology1 / 3

    10 rows

    PolicyPayerEffective Date
    Dental Anesthesia ServicesProvidence Health Plan2026-10-01
    Anesthesia Services for Interventional Pain Management Procedures in an AdultCigna2026-09-15
    General Anesthesia and Conscious Sedation ServicesUnitedHealthcare2026-09-01
    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use DisordersPremera Bluecross2026-07-01
    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use DisordersPremera Bluecross2026-07-01
    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use DisordersPremera Bluecross2026-07-01
    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use DisordersPremera Bluecross2026-07-01
    Elective Inpatient Services (for Idaho Only)UnitedHealthcare2026-06-01
    Sites of Servicepriority health2026-06-01
    Coverage for Ambulatory Surgery Unit (ASU)/Outpatient Facility and Anesthesia for Dental Servicesuniverahealthcare2026-05-21

    Related Codes

    CPT-42800-OROPHARYNGEAL-BIOPSY

    CPT 42800: Biopsy, Oropharynx

    CPT-42804-NASOPHARYNGEAL-LESION-BIOPSY

    CPT 42804: Biopsy of Visible Nasopharyngeal Lesion

    CPT-42806-NASOPHARYNGEAL-BIOPSY-UNKNOWN-PRIMARY-LESION

    CPT 42806: Biopsy of Nasopharyngeal Lesion, Unknown Primary

    CPT-42808-PHARYNGEAL-LESION-DESTRUCTION-LASER-CRYOSURGERY

    CPT 42808: Pharynx Lesion Destruction (Laser, Cryosurgery, Electrocautery)

    CPT-42809-PHARYNX-FOREIGN-BODY-REMOVAL

    CPT 42809: Removal of Foreign Body from Pharynx

    CPT-42810-BRACHIAL-CLEFT-CYST-EXCISION

    CPT 42810: Excision of Brachial Cleft Cyst, Lateral Neck

    CPT-42815-BRACHIAL-CLEFT-CYST-EXCISION

    CPT 42815: Excision of Brachial Cleft Cyst, Lateral Neck

    CPT-42821-TONSILLECTOMY-ADENOIDECTOMY-AGE-12-PLUS

    CPT 42821: Tonsillectomy with Adenoidectomy, Age 12 or Older

    CPT-42825-PEDIATRIC-TONSILLECTOMY-UNDER-12

    CPT 42825: Tonsillectomy in Patients Under 12 Years

    CPT-42826-TONSILLECTOMY-AGE-12-AND-OLDER

    CPT 42826: Tonsillectomy for Patients Age 12 and Older

    Showing 1–10 of 22

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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    42821
    Tonsillectomy and adenoidectomy; age 12 or over
    Alternative age-based code for patients aged 12 years and older; choose based on patient age.
    42826Tonsillectomy, primary or secondary; younger than age 12Used when adenoidectomy is not performed and only a tonsillectomy is performed in a patient younger than 12.
    42830Adenoidectomy, primary; younger than age 12Used when only the adenoids are removed in a patient younger than 12; may be billed instead of combined code when tonsillectomy is not performed.
    42831Adenoidectomy, primary; age 12 or overAge-specific adenoidectomy code for patients 12 years and older; select based on patient age.