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CPT 42820: Tonsillectomy and Adenoidectomy, Patient Younger Than 12
CPT code 42820 denotes a combined tonsillectomy and adenoidectomy performed in patients younger than 12 years. This pediatric surgical code is commonly used for obstructive sleep-disordered breathing from tonsillar and adenoidal hypertrophy or for recurrent tonsillar and adenoidal infections. Nationally, the procedure is a high-volume pediatric ENT operation with implications for surgical capacity, perioperative care protocols, and payer coverage policies.
Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare. Readers will find contextual clinical information about indications for the procedure, typical sites of service (hospital operating room and ambulatory surgical center), and how payers commonly approach coverage and coding for pediatric tonsillectomy and adenoidectomy. The publication summarizes benchmark considerations, common related procedure codes, and relevant ICD-10 diagnoses used to support medical necessity.
This summary is intended for clinicians, billing professionals, and policy analysts seeking a concise national overview of the code’s clinical role and payer relevance. Data not available in the input is noted where applicable; the focus remains on code definition, clinical context, and the payer landscape at a high level.
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Billing Code Overview
CPT code 42820 describes surgical removal of the tonsils and adenoids in a patient younger than 12 years old. This procedure is classified as a tonsillectomy with adenoidectomy for pediatric patients and is typically performed for obstructive symptoms or recurrent infections.
Service type: Surgical - Otolaryngology (ENT)
Typical site of service: Hospital operating room or ambulatory surgical center
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.