I would 42826. below is coding clinic on unilateral tonsillectomy don't add 52
Tonsillectomy, unilateral
Coding Clinic for HCPCS - Fourth Quarter 2021 Page: 11 Effective Date: December 9, 2021
ASK THE EDITOR
QUESTION 4
An adult patient presented with a left peritonsillar and retropharyngeal abscess. Since the abscess was on the left side only, a decision was made to perform a unilateral tonsillectomy. As the CPT codes that capture tonsillectomies, code range 42820-42836, are inherently bilateral procedures, for facility reporting, what is the appropriate CPT code for a unilateral tonsillectomy?
ANSWER
Assign CPT code 42826, Tonsillectomy, primary or secondary; age 12 or over, for the unilateral tonsillectomy. Although CPT code 42826 is an inherently bilateral procedure, for facility reporting there are no available modifiers to indicate the procedure was performed unilaterally. It is not appropriate to utilize Modifiers RT, Right Side or LT, Left Side to indicate laterality with a CPT code that represents a bilateral procedure.
In addition, there are no appropriate modifiers for facility use when a reduced procedure is carried out as intended. Since facility reporting is based upon resources utilized and not the work performed, in this example, the code descriptor for CPT code 42826 does not prohibit the facility from reporting this code when the procedure to remove a unilateral tonsil is carried out as intended. Please note, this advice supersedes a similar example published in Coding Clinic for HCPCS, First Quarter 2012, Page 11.
From what I read definitely not radial below is the Coders desk reference of that procedure:
42842-42845
The physician removes the tonsils, tonsillar pillars, and/or the retromolar trigone, along with any affected area of the maxilla or mandible involved in the tumor. First, the physician performs a tracheostomy. The involved tissue is resected. In addition to the above areas, radical resection may include a hemiglossectomy or a total glossectomy, as well as a full neck dissection. In 42842, the wound is so extensive that it is packed open and grafted at a later session. In 42844, the wound is less extensive and can be closed primarily with sutured layers. In 42845, a flap is rotated from the chest. If the wound included a resection of the mandible or maxilla, a fibular bone graft or a metal plate may be used to reconstruct the jaw.