Question 1

What is ICD-10 code J36?

Accepted Answer

J36 is the ICD-10-CM diagnosis code for Peritonsillar abscess. It belongs to the ICD-10-CM chapter for diseases of the respiratory system (j00-j99). J36 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. J36 is part of the FY2026 ICD-10-CM code set published by the CMS National Center for Health Statistics and used on Medicare, Medicaid, and commercial claims in the United States.

Question 2

Is J36 an HCC code?

Accepted Answer

No. J36 is a billable ICD-10-CM code but does not map to any payment HCC category under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can still be reported on Medicare Advantage encounter data submissions, but it does not contribute to the beneficiary's Risk Adjustment Factor (RAF) score and therefore does not affect the risk-adjusted capitation payment to the plan. V28 reached 100% phase-in for payment year 2026.

Question 3

Is J36 billable?

Accepted Answer

Yes. J36 is a billable ICD-10-CM code that can be reported on professional and institutional claims as a primary or secondary diagnosis when the provider documentation supports the specific condition described. Billable codes in ICD-10-CM are coded to the highest level of specificity available for the documented diagnosis. J36 is current for fiscal year 2026 and remains in the active CMS ICD-10-CM code set published by the National Center for Health Statistics.

Question 4

What is the V28 vs V24 difference for J36?

Accepted Answer

J36 does not map to a payment HCC under either the CMS-HCC V28 risk adjustment model or the older V24 model. V28 reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition. Because neither model rewards J36 with a risk adjustment factor, it contributes zero to a Medicare Advantage beneficiary's RAF score in either version. Coders should check whether provider documentation supports a more specific child code that does map to a payment HCC.

Question 5

What should coders know when reporting J36?

Accepted Answer

Verify documentation specifies peritonsillar abscess rather than other throat infections like retropharyngeal abscess (J39.0) or epiglottitis (J05.10) Check if the abscess required drainage or aspiration, as this may be coded separately with a procedure code and could affect severity assessment

J36

Is J36 an HCC code?

What This Code Means

Coding Tips

Includes

Excludes 1 — Do NOT code together

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Code Hierarchy

Open J36 in the Interactive Encoder