ICD-10 Guide

J35.1

Hypertrophy of tonsils

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/06/2025

Code Description

ICD-10 J35.1 is a billable code used to indicate a diagnosis of hypertrophy of tonsils.

Key Diagnostic Point:

Hypertrophy of tonsils, classified under ICD-10 code J35.1, refers to the abnormal enlargement of the tonsils, which are lymphoid tissues located at the back of the throat. This condition can lead to obstructive sleep apnea, recurrent throat infections, and difficulty swallowing. Clinically, patients may present with symptoms such as snoring, mouth breathing, and chronic sore throat. The anatomy involved includes the palatine tonsils, which can become enlarged due to chronic inflammation or infection. Disease progression can vary; in some cases, hypertrophy may resolve with treatment of underlying infections, while in others, surgical intervention such as tonsillectomy may be necessary. Diagnostic considerations include a thorough clinical history, physical examination, and possibly imaging studies to assess the degree of enlargement and its impact on the airway. It is essential for healthcare providers to differentiate hypertrophy from other conditions such as tonsillitis or neoplasms, which may require different management strategies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Diagnostic complexity: Moderate, as it requires clinical evaluation and sometimes imaging.
Treatment complexity: Moderate, with options ranging from observation to surgical intervention.
Documentation requirements: Requires detailed clinical notes and possibly imaging reports.
Coding specificity: Specific to hypertrophy, but related codes may exist for other tonsil conditions.

Audit Risk Factors

Common coding errors: Misclassification with other tonsil conditions.
Documentation gaps: Incomplete clinical notes regarding symptoms and treatment history.
Billing challenges: Denials may occur if documentation does not clearly support the diagnosis.

Specialty Focus

Medical Specialties

Primary medical specialty: Otolaryngology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Secondary specialty: Pediatrics

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

Hypertrophy of tonsils can significantly impact a patient's quality of life, leading to sleep disturbances and recurrent infections. In pediatric populations, it is a common cause of obstructive sleep apnea, which can affect growth and development. Understanding the prevalence and management of this condition is essential for improving population health outcomes and reducing healthcare utilization related to complications from untreated tonsil hypertrophy.

ICD-9 vs ICD-10

Reimbursement & Billing Impact

Reimbursement considerations may vary by payer, but typically, surgical interventions such as tonsillectomy are well-covered if medically necessary. Common denials may arise from insufficient documentation or lack of evidence for the need for surgery. Best practices include maintaining thorough clinical notes, ensuring all symptoms are documented, and providing clear justification for any surgical procedures performed.

Resources

Clinical References

•
ICD-10 Official Guidelines for J00-J99
•
Clinical Documentation Requirements

Coding & Billing References

•
ICD-10 Official Guidelines for J00-J99
•
Clinical Documentation Requirements

Frequently Asked Questions

What specific conditions are covered by J35.1?

J35.1 specifically covers hypertrophy of the palatine tonsils, which may occur due to chronic infections or other inflammatory processes. It does not include acute tonsillitis or neoplastic conditions.

When should J35.1 be used instead of related codes?

J35.1 should be used when there is clear documentation of tonsil hypertrophy without acute infection or other complicating factors. If acute tonsillitis is present, J35.0 would be more appropriate.

What documentation supports J35.1?

Documentation should include a detailed history of symptoms, physical examination findings indicating tonsil size, and any relevant imaging studies that support the diagnosis of hypertrophy.

ICD-10 J35.1 is a billable code used to indicate a diagnosis of hypertrophy of tonsils.