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TONSIL REIMBURSEMENT FACT SHEET 2008
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CPT code1
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Procedure
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National Average Medicare Payment2
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42820
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Tonsillectomy and adenoidectomy; under age 12
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$268.51
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42821
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Tonsillectomy and adrenoidectomy; age 12 or over
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$281.84
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42825
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Tonsillectomy, primary or secondary; under age 12
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$241.09
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42826
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Tonsillectomy, primary or secondary; age 12 or over
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$233.09
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42830
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Adenoidectomy, primary; under age 12
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$190.05
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42831
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Adenoidectomy, primary; age 12 or over
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$205.29
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42835
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Adenoidectomy, secondary; under age 12
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$166.82
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42836
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Adenoidectomy, secondary; age 12 or over
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$224.71
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42870
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Excision or destruction lingual tonsil, any method (separate procedure)
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$528.27
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Hospital Outpatient Department
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APC
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APC Description
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2008 Medicare Payment3
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258
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Tonsil and adenoid procedures (CPT codes 42820, 42821, 42825, 42826, 42830, 42831, 42835, 42836, 42870)
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$1,417.55
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Freestanding Ambulatory Surgery Center
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CPT-4 Codes
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2008 Medicare Payment4
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For CPT Codes 42820, 42870
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$612.85
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For CPT Codes 42825, 42826, 42830, 42831, 42835, 42836
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$702.85
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For CPT Codes 42821
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$768.10
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ICD-9 Code5
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Description
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28.2
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Tonsillectomy without adenoidectomy
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28.3
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Tonsillectomy with adenoidectomy
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28.5
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Excision of lingual tonsil
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28.6
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Adenoidectomy without tonsillectomy
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28.99
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Other operations on tonsils and adenoids
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NOTE: ICD-9 codes are grouped into Diagnoses Related Groups (DRGs) for Medicare reimbursement using a patient's diagnoses, procedures performed, age, sex and discharge status. One DRG is assigned to each inpatient stay.
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DRG
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Description
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Average Length of Stay (Days)6
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National Average DRG Payment6
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133
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Other ear, nose, mouth & throat O.R. procedures w CC/MCC
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5.8
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$7,715.48
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134
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Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC
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2.1
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$5,100.58
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