AAO41: Tonsillectomy: Post-Tonsillectomy Hemorrhage+

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High Priority Status: Yes / Outcome

CBE Number: N/A

Measure Description:

Percentage of patients aged 1 year and older who underwent a tonsillectomy and had a post-tonsillectomy hemorrhage requiring reevaluation or surgical intervention within the 21-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:

1. Patients aged 1-18 years who underwent a tonsillectomy
2. Patients aged 19 years and older who underwent a tonsillectomy
3. Patients aged 1-18 years old who underwent a tonsillectomy
4. Patients aged 19 years and older who underwent a tonsillectomy

 Denominator Exclusion:

Patients with known bleeding and/or clotting disorders

Denominator Criteria:

            Patients aged 1 year and older

AND

Procedure: Tonsillectomy

AND NOT

Diagnosis History: Bleeding and/or Clotting Disorders

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

Numerator:

1. Patients who experienced post-tonsillectomy hemorrhage that required reevaluation or surgical intervention within 1 day post-procedure (primary hemorrhage)
2. Patients who experienced post-tonsillectomy hemorrhage that required reevaluation or surgical intervention within 1 day post-procedure (primary hemorrhage)
3. Patients who experienced post-tonsillectomy hemorrhage that required reevaluation or surgical intervention between 2 and 21 days post-procedure (secondary hemorrhage)
4. Patients who experienced post-tonsillectomy hemorrhage that required reevaluation or surgical intervention between 2 and 21 days post-procedure (secondary hemorrhage)
5. Total patient performance weighted average of rates 1 and 2 (primary hemorrhage)

 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:

None

Measure Classifications:

• Submission Pathway: Traditional MIPS
• Measure Type: Outcome
• High Priority Type: Outcome
• Care Setting(s): Ambulatory Care: Ambulatory Care: Clinician Office/Clinic; Ambulatory; Ambulatory Surgical Center; Ambulatory Care: Hospital; Hospital Outpatient; Outpatient Services; Office Based Surgery Center
• 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 follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding).

Recommendation based on observational studies with a preponderance of benefit over harm.

Clinicians should determine their rate of primary and secondary post-tonsillectomy bleeding at least annually.

Recommendation based on observational studies with a preponderance of benefit over harm.

The purpose of these statements is to encourage self-assessment and accurate documentation by clinicians who perform tonsillectomy, to determine how their personal rates of bleeding compares with expected rates based on audit data and published reports.

A quality improvement opportunity addressed by these guideline key action statements is to encourage clinicians to systematically obtain follow-up data regarding bleeding for their tonsillectomy patients and to facilitate calculation of clinician-specific bleeding rates for comparison with national benchmarks.

Rationale:

Tonsillectomy is one of the most common procedures for treatment of tonsillitis and tonsillar enlargement that can cause conditions like obstructive sleep apnea hypopnea syndrome. Post-tonsillectomy hemorrhage can occur and be identified as a primary hemorrhage or a secondary hemorrhage. A minor post-operative hemorrhage can lead to complications like shock, airway obstruction, need for a blood transfusion, severe hemorrhage, or lethal hemorrhage.

A study done in 2021 to identify risk factors contributing to primary and secondary post-operative hemorrhage in pediatric tonsillectomy patients. Although tonsillectomy is a well-tolerated surgery, postoperative hemorrhage is still a common complication, even minor bleeding is often persistent and develops into severe hemorrhage. Lethal post-tonsillectomy hemorrhage is unexpected and unpredictable and requires immediate and adequate treatment. It can result in significant morbidities, such as shock, airway obstruction and the need for blood transfusion. The authors concluded that coblation tonsillectomy and less than 5 years’ experience of surgeon contribute to the tendency for primary hemorrhage. Age and time of onset are responsible for secondary hemorrhage.

Xu B, Jin HY, Wu K, Chen C, Li L, Zhang Y, Gu WZ, Chen C. Primary and secondary postoperative hemorrhage in pediatric tonsillectomy. World J Clin Cases. 2021 Mar 6;9(7):1543-1553. doi: 10.12998/wjcc.v9.i7.1543. PMID: 33728298; PMCID: PMC7942054.

 Supporting Clinical Practice Guideline (CPG):

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

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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