ICD-10 J36
Billable / Specific CCPeritonsillar abscess
About ICD-10-CM J36
ICD-10-CM code J36 represents Peritonsillar abscess. This is a billable/specific code in the Respiratory System chapter (block J36). The 2026 edition of ICD-10-CM J36 became effective on October 1, 2025.
Coding Tips for J36
Specialist guidance from the PayerReady Medical Coding Team. Specificity warnings, HCC capture rules, sequencing notes.
J36 is designated CC for MS-DRG grouping. On inpatient claims, this code can shift the DRG to the with-CC variant when documented as a present-on-admission secondary diagnosis. Hospital CDI programs flag CC opportunities during chart review. Failure to capture this code may leave 30 to 80 percent of the inpatient stay revenue unrealized.
Type 1 Excludes
Pure excludes, these codes can never be coded together with J36. The conditions are mutually exclusive (e.g., congenital vs acquired forms).
- acute tonsillitis (J03.-)
- chronic tonsillitis (J35.0)
- retropharyngeal abscess (J39.0)
- tonsillitis NOS (J03.9-)
Includes
- abscess of tonsil
- peritonsillar cellulitis
- quinsy
Use Additional Code
When coding J36, also report these additional codes when applicable.
- code (B95-B97) to identify infectious agent.
Inpatient DRG Impact, CC
codes Peritonsillar abscess. As a Complication/Comorbidity (CC), this contributes to DRG severity adjustment when documented alongside the principal diagnosis.
Medicare LCD Coverage for J36
Local Coverage Determinations (LCDs) from CMS MACs that list J36 as a covered diagnosis.
Showing top 10 of 28 total . Click a CPT for full coverage scope.
Commercial Payer Coverage
Coverage policies from major commercial payers referencing J36.
1 Medicare
CPT Codes Commonly Billed with J36
Procedures frequently paired with this diagnosis based on PayerReady's Dx↔Px linkage data.
- 42820 Tonsillectomy — chronic tonsillitis, hypertrophic tonsils, sleep apnea, peritonsillar abscess, acute tonsillitis, mouth breathing, dysphagia ENT
Convert J36 to ICD-9-CM
Per CMS General Equivalence Mappings (GEMs), useful for legacy data review and historical claim analysis.
| ICD-10 | ICD-9 | Mapping Flags |
|---|---|---|
| J36 | 475 | 00000 |
Flags format (5 digits): Approximate · No Map · Combination · Scenario · Choice List. Source: CMS 2017 GEMs (final version).
Codes Adjacent To J36
Other codes in section J30-J39 (Other diseases of upper respiratory tract).
ICD-10 J36, Billing FAQ
Is ICD-10 code J36 billable? +
Yes, J36 is a billable ICD-10-CM code that can appear as a primary or secondary diagnosis on claims.
What codes are Type 1 Excludes for J36? +
Type 1 Excludes (never code together with J36): acute tonsillitis (J03.-); chronic tonsillitis (J35.0); retropharyngeal abscess (J39.0)
Is J36 a CC or MCC for inpatient DRG? +
Yes, this code is designated as CC. Documenting as a secondary diagnosis on inpatient claims can shift the DRG to a higher-weighted category.
What CPT codes are commonly billed with J36? +
Procedures frequently paired with J36 include: 42820.
What ICD-9 codes does J36 map to? +
Per CMS GEMs, J36 maps to ICD-9 codes: 475. Useful for legacy data review and historical claim analysis.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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