CPT® Code 42826

A tonsillectomy, whether primary or secondary, is a surgical procedure aimed at the removal of the tonsils in patients aged 12 years or older. The term "primary tonsillectomy" refers to the initial surgical intervention to excise the tonsils, while "secondary tonsillectomy" indicates a repeat operation that may be necessary to eliminate any residual tonsil tissue or to address regrowth of the tonsils after a previous surgery. During the procedure, a mouth prop is utilized to keep the mouth open and stable, allowing the surgeon clear access to the tonsils. Various techniques can be employed for the dissection of the tonsils, including the use of scissors and curettes for both sharp and blunt dissection, cautery, radiofrequency, laser ablation, or a harmonic scalpel. The standard dissection and snare technique involves making an incision in the mucosa with a sickle knife, starting at the superior pole of the tonsil and progressing inferiorly through the surrounding loose connective tissue. Once the tonsil is adequately 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. Hemostasis is achieved through various methods, including applying pressure, using suture ties, or employing cautery to control any bleeding. It is important to note that CPT® code 42825 should be used for patients younger than 12 years, while CPT® code 42826 is designated for patients aged 12 and older.