Question

PREOPERATIVE DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.
POSTOPERATIVE DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.
PROCEDURE PERFORMED: Tonsillectomy and adenoidectomy.
OPERATIVE NOTE: The patient is a 15-year-old woman who was seen in the office and diagnosed with the above condition. Decision was made in consultation with the patient to undergo the procedure. She was admitted through the same-day department and taken to the operating room, where she was administered general anesthetic by intravenous injection. She was then intubated endotracheally. The Jennings gag was inserted into the mouth and expanded; this was secured to a Mayo stand. Two red rubber catheters were placed through the nose and brought out through the mouth; these were secured with snaps. This was done to elevate the palate. A laryngeal mirror was placed in the nasopharynx. The adenoid tissue was visualized. Using suction cautery, the adenoid tissue was removed in systemic fashion. Once this was completed, the red rubbers were released and brought out through the nose. The right tonsil was grasped with an Allis forceps and retracted medially using a harmonic scalpel, and the capsule was entered bilaterally. The tonsil was removed from its fossa in an inferior fashion, and one small area was cauterized. The left tonsil was then grasped with an Allis forceps and retracted medially. Again, the capsule was identified laterally, and the harmonic scalpel was used to remove the tonsil from its fossa in an inferior to superior fashion. Once this was completed, the bed was inspected, and two small areas were cauterized here. Three tonsillar sponges were soaked in 1% Marcaine with epinephrine; one was placed in the nasopharynx, and one in each tonsil bed. These were left in position for 5 minutes, and at the end of this interval they were removed. The beds were inspected. No further bleeding was noted. The gag was then removed from the mouth. The TMJ joint was checked. The patient was allowed to recover from a general anesthetic and taken to the post anesthesia care unit in stable condition. There were no complications during this procedure.
PATHOLOGY REPORT LATER INDICATED: Benign tonsil and adenoid tissue.

CPT Code: ________

ICD-10-CM: ________

Answer 1

CPT code: 42821

42821= tonsillectomy and adenoidectomy above the age of 12 years.

Where as 42820 indicates tonsillectomy and adenoidectomy under the age of 12 years.

ICD 10 CM:

Code: J35.3 = Hypertrophy of tonsils and addictions.