Summary & Overview
CPT 42826: Tonsillectomy for Patients Age 12 and Older
Headline: CPT code 42826: Tonsillectomy for Patients Aged 12 Years and Older
Lead: CPT code 42826 identifies an initial, recurrent, or secondary tonsillectomy performed in patients who are 12 years of age or older. This surgical code is relevant to otolaryngology practices, ambulatory surgery centers, and hospital surgical departments and affects national billing patterns for common airway and infection-related indications.
CPT code 42826 represents the standardized billing descriptor for adult and adolescent tonsil removal when the patient is 12 years or older. Nationally, this code matters because tonsillectomy remains a frequently performed ENT surgery with implications for surgical capacity, anesthesia services, and reimbursement across public and commercial payers. The code is used for primary, repeat, and secondary procedures, ensuring consistent reporting for clinical and administrative workflows.
Key payers covered include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for the procedure, typical sites of service, and the payer scope included in this review. The publication outlines expected benchmarks and coding considerations, highlights recent policy or coverage updates where applicable, and situates CPT code 42826 within common surgical service lines.
This summary is intended for billing managers, surgical administrators, and policy analysts seeking a national perspective on coding, coverage, and the clinical framing of tonsillectomy in patients aged 12 and older.
Billing Code Overview
CPT code 42826 describes a tonsillectomy procedure performed in patients aged 12 years or older. The code applies to initial, recurrent, or secondary tonsillectomy interventions.
Service type: Surgical — Otorhinolaryngology (ENT) procedure
Typical site of service: Hospital inpatient or outpatient surgical center, or ambulatory surgical center
Clinical & Coding Specifications
Clinical Context
A typical patient is an adolescent or adult (age 12 years or older) presenting with recurrent tonsillitis, obstructive sleep-disordered breathing due to tonsillar hypertrophy, or chronic tonsillar hypertrophy unresponsive to medical therapy. The clinical workflow begins with outpatient evaluation by an otolaryngologist (ENT) including history, physical exam with oropharyngeal inspection, review of prior antibiotic response and infection frequency, and assessment of sleep symptoms. Preoperative workup includes medical clearance, review of bleeding history or anticoagulant use, and informed consent. On the day of service the patient presents to an ambulatory surgery center or hospital outpatient surgery department; anesthesia is administered (general endotracheal or mask) and the surgeon performs a tonsillectomy using cold dissection, electrocautery, or other accepted technique. Specimens are not typically sent for pathology unless indicated. Postoperative recovery includes monitoring for airway compromise and hemorrhage, discharge with analgesia and activity restrictions, and follow-up in clinic.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
59 | Distinct procedural service | When a separate, unrelated procedure is performed on the same date not considered bundled with the tonsillectomy |
50 |