CPT® Code 42825

A tonsillectomy, whether classified as primary or secondary, is a surgical procedure aimed at the removal of the tonsils in patients who are younger than 12 years of age. A primary tonsillectomy is the initial surgical intervention to excise the tonsils, which are lymphoid tissues located at the back of the throat that can become enlarged or infected. In contrast, a secondary tonsillectomy is performed when there is a need to remove any residual tonsil tissue or to address regrowth after a previous tonsillectomy. The procedure typically involves the use of a mouth prop to keep the mouth open and facilitate access to the tonsils. During the surgery, clamps are applied to the tonsils to provide traction, allowing for effective dissection. Various techniques may be employed for the dissection of the tonsils, including the use of scissors, curettes, cautery, radiofrequency, laser ablation, or a harmonic scalpel. The standard dissection and snare technique involves incising the mucosa with a sickle knife, beginning at the superior pole of the tonsil and progressing inferiorly through the connective tissue. Once the tonsil is fully dissected, a snare is placed around it, and the tonsil is amputated by tightening the snare loop. After the tonsil is removed, the surgical site is carefully inspected to ensure that any remaining tonsil tissue is excised, and bleeding is managed through pressure, sutures, or cautery. This procedure is specifically coded as CPT® 42825 for patients under the age of 12, while CPT® 42826 is designated for patients aged 12 and older.