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

associationbase_codecode_typeestimated_chargeitem_typename
142820CPT4184.5indexRemoval of tonsils and adenoid glands for patients younger than age 12
142820CPT885professional_feeRemoval of tonsils and adenoid glands for patients younger than age 12
0.984960343360Revenue Codefacility_feeOR services
0.861170CPT800professional_feeAnesthesia for intraoral procedures
0.788160323636Revenue Codefacility_feeDrugs requiring detailed coding
0.782211802J1100HCPCS25.3facility_feeDexamethasone sodium phosphate injection
0.739998504J2405HCPCS42.85facility_feeOndansetron hydrochloride injection
0.613J1100HCPCS6.105professional_feeDexamethasone sodium phosphate injection
0.582481169J3010HCPCS12.1facility_feeFentanyl citrate injection
0.582J2405HCPCS6.78professional_feeOndansetron hydrochloride injection
0.504751334J2704HCPCS16.5facility_feePropofol injection
0.502968025250Revenue Codeancillary_servicePharmacy
0.459906719710Revenue Codeancillary_serviceRecovery Room
0.447149199370Revenue Codeancillary_serviceAnesthesia

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

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