AAO40: Tonsillectomy: Post-Tonsillectomy Pain Management in Pediatric Patients+

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High Priority Status: Yes / Opioid-related

CBE Number: N/A

 Measure Description:

Percentage of patients aged 12 years and younger who underwent a tonsillectomy and were given opioids within the 5-day postoperative period.

Instructions:

This measure is to be submitted each time a patient underwent a tonsillectomy during the performance period. This measure may be submitted by clinicians based on the services provided and the measure-specific denominator coding.

 Denominator:

Patients aged 12 years and younger who underwent a tonsillectomy.

 Denominator Exclusion:

Patients who were on opioid medications prior to procedure.

Denominator Criteria:

            Patients aged 12 years and younger

AND

Procedure: Tonsillectomy

AND NOT

Current Prescription for: Opioid Medication

For a list of codes that qualify as denominator eligible visits, reference Addendum attached.

 Numerator:

Patients who were given opioids within the 5-day postoperative period.

 Numerator Note:

Day 0 is the day of surgery; Day 1 is the day after surgery

INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

Denominator Exceptions:

Patients with an allergy or contraindication to acetaminophen and non-steroidal anti-inflammatory medications.

Measure Classifications:

• Submission Pathway: Traditional MIPS
• Measure Type: Process
• High Priority Type: Opioid-related
• Care Setting(s): Ambulatory Care: Ambulatory; Ambulatory Care: Clinician Office/Clinic; Ambulatory Care: Hospital; Ambulatory Surgical Center; Hospital Outpatient; Office Based Surgery Center; Outpatient Services
• Includes Telehealth: No
• Number of Performance Rates: 1
  • Inverse measure: Yes
  • Continuous measure: No
  • Proportional measure: Yes
  • Ratio measure: No
  • Risk Adjusted measure: No

Clinical Recommendation Statement:

The following evidence statements are extracted from the referenced clinical guidelines: AAO-HNS Tonsillectomy in Children Guideline (2019):

Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. Strong recommendation based on systematic review and randomized controlled trials with a preponderance of benefit over harm.

The purpose of this statement is to inform surgeons, other health care providers, and consumers of nonopioid alternatives for optimal pain control to decrease morbidity after tonsillectomy in children.

A quality improvement opportunity addressed by this guideline key action statement is to promote awareness that ibuprofen is a safe and effective analgesic for use after tonsillectomy, when used alone or in combination with acetaminophen.

Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. Strong recommendation against administering or prescribing based on observational studies with dramatic effect and supporting high-level pharmacogenetic studies with a preponderance of benefit over harm.

The purpose of this statement is to inform surgeons that the prescription or administration of codeine, or any medication containing codeine, is not recommended in children <12 years of age after tonsillectomy.

A quality improvement opportunity addressed by this guideline key action statement is to reduce harmful therapy.

 Rationale:

Tonsillectomy is one of the most common pediatric surgical procedures done in the United States. Effective treatment during the post-operative period includes the use of acetaminophen, ibuprofen, or alternating both and recommends against the use of opioids. Despite the risks of opioid consumption, there are significant knowledge gaps identified regarding the use of intentionally prescribed opioid medication versus non-opioid prescription.

A 2023 study was conducted to review opioid prescribing habits post-tonsillectomy and the impacts of opioid education sessions for physicians and a standardized prescription protocol. Although evidence shows the use of acetaminophen, non-steroidal anti-inflammatory drugs, or a combination of both is strongly recommended during the post-operative period for a tonsillectomy, the use of opioids remains and varies amongst providers. Adequate analgesia is crucial for the resumption of oral intake, early recovery, and prevention of readmission. The use of opioids increases the risk of nausea, respiratory depression, drug-drug interactions, and abuse potential. The authors concluded that physician education regarding opioid prescribing post-tonsillectomy and a standardized prescription protocol reduced the average number of initial oxycodone doses per patient.

Amin, S. N., Thompson, T. Reducing Pediatric Post tonsillectomy Opioid Prescribing: a quality improvement initiative. Otolaryngology and Head and Neck Surgery/Otolaryngology–head and Neck Surgery (2023). 170(2), 610–617. https://doi.org/10.1002/ohn.534

Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;(11):1-25

Supporting Clinical Practice Guideline:

For more details, reference the Clinical Practice Guideline: Tonsillectomy in Children (Update) [2019]

© 2026 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the measures for commercial gain, or incorporation of the measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the measures require a license agreement between the user and the American Academy of Otolaryngology – Head and Neck Surgery Foundation.

The measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. The measure and specifications are provided “as is” without warranty of any kind. Neither the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF), nor its members shall be responsible for any use of the measure. The AAO-HNSF and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.

Addendum