42820
Removal of tonsils and adenoid glands patient younger than age 12
Our Work > Good Faith Estimates > Removal of Tonsils
Recent regulations require hospitals and health plans to publish prices of a subset of services. The hospital rule requires publication of “shoppable services,” those that can be scheduled in advance by a consumer. The Transparency in Coverage rule requires a list of 500 items and services to be published. Removal of Tonsils and adenoid glands patient younger than age 12 appears on both lists, and there is a standard service package available for it.
Tonsillectomy is the surgical removal of the tonsils, two oval-shaped pads of tissue at the back of the throat. The procedure is usually performed for sleep-disordered breathing but may still be a treatment when tonsillitis occurs frequently or doesn’t respond to other treatments.
Use of this service is restricted to patients younger than 12. For adolescents and adults, another service package should be used. Your service utilization may vary from this service package for a number of reasons, including your unique clinical profile and where you recieve your services.
This Service Package was generated using outpatient care setting claims. However, this service package may also be performed in the below care settings. Please confirm with your provider in which care setting you will receive services, as this may affect your cost.
- Inpatient: Discuss with your provider
- Outpatient facility: 60%
- Free standing ASC: 40%
Item Definitions
Index
Index
this is the fee for the service being defined; note that other codes may be used to define a similar service
Facility Fee
Facility Fee
these fees are most commonly associated with the index event; these may also be
paid to the facility in addition to the index fee
Professional Fee
Professional Fee
these fees are paid to clinicians for the work associated with this service
Optional Fee
Optional Fee
these services are often also billed with the index event, however may vary based on the patient’s individual circumstances
Ancillary Service
Ancillary Service
these are supply codes that identify other services that may be billed with the index event
Proposed Technical Definition
| association | base_code | code_type | estimated_charge | item_type | name |
|---|---|---|---|---|---|
| 1 | 42820 | CPT | 4184.5 | index | Removal of tonsils and adenoid glands for patients younger than age 12 |
| 1 | 42820 | CPT | 885 | professional_fee | Removal of tonsils and adenoid glands for patients younger than age 12 |
| 0.984960343 | 360 | Revenue Code | facility_fee | OR services | |
| 0.861 | 170 | CPT | 800 | professional_fee | Anesthesia for intraoral procedures |
| 0.788160323 | 636 | Revenue Code | facility_fee | Drugs requiring detailed coding | |
| 0.782211802 | J1100 | HCPCS | 25.3 | facility_fee | Dexamethasone sodium phosphate injection |
| 0.739998504 | J2405 | HCPCS | 42.85 | facility_fee | Ondansetron hydrochloride injection |
| 0.613 | J1100 | HCPCS | 6.105 | professional_fee | Dexamethasone sodium phosphate injection |
| 0.582481169 | J3010 | HCPCS | 12.1 | facility_fee | Fentanyl citrate injection |
| 0.582 | J2405 | HCPCS | 6.78 | professional_fee | Ondansetron hydrochloride injection |
| 0.504751334 | J2704 | HCPCS | 16.5 | facility_fee | Propofol injection |
| 0.502968025 | 250 | Revenue Code | ancillary_service | Pharmacy | |
| 0.459906719 | 710 | Revenue Code | ancillary_service | Recovery Room | |
| 0.447149199 | 370 | Revenue Code | ancillary_service | Anesthesia |
Captured Spending (N=40,000)
| Decile | Base Fee (Facility + Professional) | Base Fee + Optional Fees |
| 1 | 1% | |
| 2 | 1% | |
| 3 | 2% | |
| 4 | 2% | |
| 5 | 3% | |
| 6 | 5% | |
| 7 | 7% | |
| 8 | 8% | |
| 9 | 11% | |
| 10 | 60% |
Our Work > Good Faith Estimates > Removal of Tonsils