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A tonsillectomy and adenoidectomy is a surgical procedure that involves the removal of the tonsils and adenoids, which are lymphoid tissues located in the throat and nasopharynx, respectively. This procedure is typically indicated for patients aged 12 years or older who experience recurrent throat infections, obstructive sleep apnea, or other related conditions. During the surgery, a mouth prop is utilized to keep the mouth open, allowing the surgeon clear access to the tonsils. The tonsils are grasped with clamps to provide traction, facilitating the dissection process. Various techniques may be employed for the dissection, including the use of scissors, curettes, cautery, radiofrequency, laser ablation, or harmonic scalpels. The standard dissection technique involves incising the mucosa with a sickle knife, starting at the superior pole of the tonsil and moving inferiorly through the connective tissue. Once the tonsil is fully dissected, it is removed using a snare technique. After the tonsillectomy, the surgical site is carefully inspected to ensure that any remaining tonsil tissue is excised, and bleeding is managed through pressure, sutures, or cautery. The adenoidectomy is performed subsequently, utilizing instruments such as an adenotome or adenoid curette, or by vaporization with a laser. The procedure is designed to alleviate symptoms associated with enlarged tonsils and adenoids, improving the patient's quality of life.
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The tonsillectomy and adenoidectomy procedure is indicated for patients aged 12 years or older who present with specific symptoms or conditions that warrant surgical intervention. These indications include:
The procedure for tonsillectomy and adenoidectomy involves several detailed steps to ensure the safe and effective removal of the tonsils and adenoids. The steps are as follows:
After the tonsillectomy and adenoidectomy, patients are monitored in a recovery area until they are stable. Post-operative care includes managing pain with prescribed medications and ensuring adequate hydration. Patients may experience throat pain, difficulty swallowing, and potential bleeding in the days following the surgery. It is essential to follow the surgeon's post-operative instructions, which may include dietary modifications and activity restrictions to promote healing. Follow-up appointments are typically scheduled to monitor recovery and address any complications that may arise.
| Short Descr | REMOVE TONSILS AND ADENOIDS | Medium Descr | TONSILLECTOMY & ADENOIDECTOMY AGE 12/> | Long Descr | Tonsillectomy and adenoidectomy; age 12 or over | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 30 - Tonsillectomy and/or adenoidectomy |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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