Hypertrophy of tonsils with hypertrophy of adenoids

This code describes the enlargement of both the tonsils and adenoids, which are lymphatic tissues located in the throat and behind the nose, respectively. This hypertrophy is not associated with active inflammation or infection of these tissues. The enlargement can lead to various symptoms due to airway obstruction.

Use this code when documentation clearly indicates chronic enlargement of both the tonsils and adenoids without an accompanying diagnosis of tonsillitis or adenoiditis. This is often seen in patients presenting with chronic mouth breathing, snoring, sleep-disordered breathing, or difficulty swallowing due to the physical obstruction.

• Ensure the documentation explicitly states hypertrophy of both tonsils and adenoids.
• Verify there is no mention of acute or chronic inflammation (tonsillitis/adenoiditis) to avoid the Excludes1 note.
• Consider additional codes for associated symptoms like sleep apnea (G47.3x) if documented.