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Adenoidectomy is a surgical procedure that involves the removal of the adenoids, which are lymphatic tissues located at the back of the nasal cavity. This procedure can be classified as either primary or secondary. A primary adenoidectomy refers to the initial surgical removal of the adenoids, while a secondary adenoidectomy is performed to remove any residual adenoid tissue or to address regrowth that may occur after the initial surgery. The procedure is typically indicated for patients aged 12 years or older, as denoted by the CPT® Code 42831. During the surgery, a mouth prop is utilized to keep the mouth open and suspended, allowing for better access to the surgical site. The adenoids can be resected using various instruments, including an adenotome, adenoid curette, or microdebrider, or they may be vaporized using a laser. The technique employed may vary based on the surgeon's preference and the specific circumstances of the case. The procedure is performed under anesthesia, and careful attention is given to controlling bleeding, which may involve the use of cautery or gauze sponges soaked in epinephrine. This detailed understanding of the adenoidectomy procedure is essential for accurate coding and billing in the healthcare setting.
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The adenoidectomy procedure is indicated for various conditions that may affect the patient's health and quality of life. These indications include:
The adenoidectomy procedure involves several key steps to ensure effective removal of the adenoids. These steps include:
After the adenoidectomy, patients are typically monitored for any immediate complications, such as excessive bleeding or difficulty breathing. Post-operative care may include pain management, hydration, and instructions for diet modifications to ensure comfort during recovery. Patients are advised to avoid strenuous activities and to follow up with their healthcare provider to assess healing and address any concerns. Recovery time can vary, but most patients can expect to return to normal activities within a week, depending on individual circumstances and adherence to post-operative care instructions.
| Short Descr | REMOVAL OF ADENOIDS | Medium Descr | ADENOIDECTOMY PRIMARY AGE 12/> | Long Descr | Adenoidectomy, primary; 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). | 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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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| Pre-1990 | Added | Code added. |
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