Otolaryngology Coding Alert

Question: We’ve seen numerous denials on claims billed with J35.03 and J35.3. We checked the LCDs for the procedure and didn’t see an issue with either code. Why are we receiving denials?

Maine Subscriber

Answer: When you receive a denial due to incompatible diagnoses, the first thing you want to check is whether the diagnoses are listed under the respective CPT^® code’s Local Coverage Determinations (LCDs). Since you’ve already addressed that and found no issue, the next step is to make sure the two diagnoses you are using are compatible with one another. In examining J35.03 (Chronic tonsillitis and adenoiditis) and J35.3 (Hypertrophy of tonsils with hypertrophy of adenoids), you’ll see the following Excludes1 note under J35.3:

• Excludes1: hypertrophy of tonsils and adenoids with tonsillitis and adenoiditis (J35.03).

Based on this note, you can now conclude that this is the reason for the claim denial. When you’re dealing with Excludes1 notes, make sure to submit the code listed under the Excludes1 note, not the code that contains the Excludes1 note. So, in this instance, you’ll resubmit the claim with code J35.03 only.