Tonsillectomy and Adenoidectomy
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Anatomy
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Diagnosis/ Condition
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Surgical treatment
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How to lead CPT code
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CPT code selection criteria
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Live chart sample
1.Anatomy
Tonsil is secondary lymphoid organ as we know that thymus and bone marrow are primary Lymphoid organ. It is the part of adaptive immune system, it means the immunity that develops when a person's immune system responds to a foreign substance or microorganism, such as after an infection or vaccination. They make special immune system cell called Lymphocytes.
2.Disease and Condition
1. Tonsillitis: Inflammation of Tonsil
2. Obstructive Sleep apnea: Tonsils are so large that block the airway
3. Malignancy of Tonsil
4. Enlargement of Adenoid
5. Infection or inflammation of adenoid.
3.Surgical treatment
Tonsillectomy: It is the surgical procedure to removal tonsils
Adenoidectomy: It is the surgical procedure to removal Adenoidectomy.
4.How to lead correct CPT Code
In CPT book ,
Excision-Tonsil- 42820,42821,42825,42826
Excision-Tonsil-Lingual- 42870
Excision-Tonsil-Radical resection- Closure with Local Flap- 42844
Excision-Tonsil-Radical resection- Closure with Other Flap- 42845
Excision-Adenoid-Primary- 12 or over- 42831
Excision-Adenoid-Primary- Under age 12- 42830
Excision-Adenoid-Secondary- 12 or over- 42836
Excision-Adenoid-Secondary- Under age 12- 42835
Excision-Adenoid-with Tonsil- 42820, 42821
5.Code selection criteria for Tonsillectomy
The code selection criteria for Tonsillectomy
1.Age
2.Removal of either tonsil or adenoid or both.
Tips 1
Primary tonsillectomy is the initial surgical removal of the tonsil or adenoid, whereas secondary tonsillectomy is a follow-up procedure to remove parts of the tonsil or adenoid that were not removed during the initial surgery or that regrew after the initial operation.
Live Sample Chart 1
PREOPERATIVE DIAGNOSIS: Adenoid hypertrophy.
POSTOPERATIVE DIAGNOSIS: Adenoid hypertrophy.
PROCEDURE PERFORMED: Adenoidectomy.
ANESTHESIA: General endotracheal
PROCEDURE: The 8 year age patient was brought into the operating room suite, anesthesia administered via endotracheal tube. Following this the patient was draped in standard fashion. The Crowe-Davis mouth gag was inserted in the oral cavity. The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril. Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer. The adenoid pad was removed without difficulty. The nasopharynx was packed. Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated. The Crowe-Davis was released.
The patient tolerated the procedure well and left the operating room in good condition.
Answer 42830 Adenoidectomy, primary; younger than age 12 The provider performs an initial adenoidectomy in a patient who is less than 12 years old.
Live Sample Chart 2
PREOPERATIVE DIAGNOSIS: Recurrent tonsillitis.
POSTOPERATIVE DIAGNOSIS: Recurrent tonsillitis.
PROCEDURE: Tonsillectomy.
COMPLICATIONS: None.
PROCEDURE DETAILS: The 6 year old patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed. A similar procedure was performed on the contralateral tonsil. Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted. The patient was then allowed to awaken and was brought to the recovery room in stable condition.
Answer 42835: Adenoidectomy, secondary; younger than age 12 The provider performs a recurrent or secondary adenoidectomy procedure in a patient who is less than 12 years old.
Live Sample Chart 3
PROCEDURE PERFORMED: Tonsillectomy and adenoidectomy.
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: The 22 years patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia. The McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied. Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.
The nasopharynx was inspected with a laryngeal mirror. The adenoid tissue was fulgurated with the suction Bovie set at 35. The catheters and the dental gauze roll were then removed. The anterior tonsillar pillars were infiltrated with 0.5% Marcaine and epinephrine. Using the radiofrequency wand, the tonsils were ablated bilaterally. If bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9. The tonsillectomy was completed.
The nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.
The patient tolerated the procedure well and left the operating room in good condition.