CPT 42836 Recurrent Adenoidectomy Reimbursement | OpenPayer

Summary & Overview

CPT 42836: Recurrent or Secondary Adenoidectomy, Age 12 and Older

CPT code 42836 represents a recurrent or secondary adenoidectomy for patients aged 12 years and older. This code captures repeat surgical removal of adenoid tissue and is used in settings where prior adenoidectomy requires additional operative intervention. Nationally, accurate use of this code matters for correct clinical classification, claims adjudication, and aggregate surgical utilization reporting for otolaryngology services.

Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines how 42836 is reported across common commercial and public payers and summarizes typical sites of service and service line context for surgical management of recurrent adenoidal disease.

Readers will find a concise clinical context for the procedure, payer coverage scope, and what to expect in claim submission and coding practice. The content covers benchmarks and policy-relevant considerations affecting coding consistency and reimbursement classification, as well as practical notes on service setting and patient age criteria. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare42836CPTAdenoidectomyENTSurgical ProcedureAmbulatory SurgeryPediatric (>12)Recurrent Surgery

Billing Code Overview

CPT code 42836 describes a recurrent or secondary adenoidectomy performed on a patient who is 12 years of age or older. This procedure involves surgical removal of adenoid tissue when prior adenoidectomy has been performed and recurrence or persistent disease necessitates repeat intervention.

Service type: Surgical procedure — recurrent or secondary adenoidectomy
Typical site of service: Ambulatory surgery center or hospital operating room

Clinical & Coding Specifications

Clinical Context

A typical patient is an adolescent or adult (age ≥12 years) presenting with recurrent adenoid-related symptoms after a prior adenoidectomy. Common indications include persistent nasal obstruction, chronic/recurrent otitis media with effusion, nasal airway compromise with hyponasal speech, or recurrent sinusitis related to residual adenoid tissue. The clinical workflow begins with an otolaryngology evaluation including history and physical exam, nasal endoscopy or flexible nasopharyngoscopy to visualize residual adenoid tissue, and audiology evaluation if middle ear disease is suspected. Imaging (lateral neck radiograph or CT) is occasionally obtained to assess adenoid size or anatomic considerations. The procedure, coded as 42836, is performed in an operating room or ambulatory surgery center under general anesthesia for patients age 12 or older. Intraoperative steps include endoscopic or indirect visualization, removal of recurrent or residual adenoid tissue with curette, microdebrider, or suction cautery as indicated, hemostasis, and inspection of the nasopharynx and Eustachian tube orifices. Postoperative care involves monitoring in PACU, standard discharge instructions, and follow-up visits to assess wound healing and symptom resolution. Typical documentation includes indication, prior adenoidectomy history, consent, anesthesia type, detailed operative findings, technique used, estimated blood loss, and postoperative condition.

Coding Specifications

Modifier	Description	When to Use
`22`

CPT 42835: Recurrent or Secondary Adenoidectomy in Children

CPT-42830-INITIAL-ADENOIDECTOMY-PEDIATRIC

CPT 42830: Initial Adenoidectomy in Patients Under 12 Years

CPT-42892-LATERAL-PHARYNGEAL-WALL-PIRIFORM-SINUS-RESECTION-CLOSURE

CPT 42892: Lateral Pharyngeal Wall or Piriform Sinus Resection with Closure

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

CPT 42806: Biopsy of Unknown Primary Lesion of the Nasopharynx

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

CPT 42821: Tonsillectomy and Adenoidectomy, Age 12 or Older

CPT-42825-PEDIATRIC-TONSILLECTOMY-UNDER-12

CPT 42825: Tonsillectomy in Patients Under 12 Years Old

CPT-42842-TONSIL-AND-ADJACENT-STRUCTURE-ABLATIVE-RESECTION

CPT 42842: Tonsil and Adjacent Structure Ablative Resection

CPT-42831-INITIAL-ADENOIDECTOMY-AGE-12-OR-OLDER

CPT 42831: Initial Adenoidectomy for Patients Aged 12 Years or Older

CPT-42800-OROPHARYNGEAL-BIOPSY

CPT 42800: Oropharyngeal Biopsy, Diagnostic

CPT-42810-BRACHIAL-CLEFT-CYST-EXCISION

CPT 42810: Excision of Brachial Cleft Cyst

Showing 1–10 of 22

Taxonomy Code	Specialty	Notes
`207P00000X`	Otolaryngology (ENT)	Primary specialty performing adenoidectomy procedures.
`2080P0003X`	Pediatric Otolaryngology	Subspecialty for adolescent patients and complex recurrent disease.
`207K00000X`	Oral and Maxillofacial Surgery	Occasionally involved for airway or simultaneous procedures.
`208100000X`	General Surgery	Rarely involved; included for completeness when cross-coverage occurs.
`208D00000X`	Anesthesiology	Provides general anesthesia for the procedure.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`J35.2`	Hypertrophy of adenoids	Primary indication for adenoidectomy when obstructive or recurrent after prior surgery.
`H65.09`	Other acute nonpurulent otitis media, unspecified ear	Otitis media contributing to recurrent symptoms and may prompt adenoid revision with tympanostomy.
`H65.4`	Chronic serous otitis media	Associated middle ear effusion often leading to concurrent tube placement with adenoid revision.
`J01.90`	Acute sinusitis, unspecified	Recurrent sinusitis related to nasopharyngeal obstruction from residual adenoid tissue.
`R09.81`	Nasal congestion	Symptom indicating persistent airway obstruction due to residual adenoid tissue.
`R49.0`	Dysphonia	Hyponasal speech or voice changes related to nasopharyngeal obstruction from adenoid regrowth.
`R04.2`	Epistaxis	Occasional indication when recurrent bleeding arises from adenoid tissue requiring surgical control.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`42830`	Adenoidectomy, younger than 12 years	Primary adenoidectomy code for patients under age 12; distinguishes age-based coding from `42836`.
`42835`	Adenoidectomy, 12 years or older (primary)	Primary adenoidectomy for patients age ≥12; `42836` is used for recurrent or secondary procedures instead of `42835` when prior adenoidectomy exists.
`69436`	Tympanostomy (myringotomy) with insertion of ventilating tube	Commonly performed concurrently for patients with otitis media with effusion related to adenoid hypertrophy.
`31231`	Nasopharyngoscopy, diagnostic, flexible or rigid	Preoperative or intraoperative endoscopic evaluation of nasopharynx and residual adenoid tissue.
`92567`	Tympanometry and reflex threshold measurements	Audiology testing performed pre- or postoperatively when middle ear effusion or hearing concerns are present.
`99100`	Anesthesia for patient of extreme age, younger than 1 year and older than 70 years	Not typically applicable for this age group but included only when age-based anesthesia modifiers or services apply (Data not available in the input if specific anesthesia codes required).

OpenPayer