Table of Contents

Basics of Community-acquired pneumonia (CAP) ICD-10 CM coding

Community-acquired pneumonia (CAP) is one of the most common infectious diseases and an important cause of mortality and morbidity worldwide. Typical bacterial pathogens that cause CAP include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

J18.9 – Pneumonia, unspecified organism

J18.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

Symptoms of Community-acquired pneumonia (CAP) ICD-10 CM coding

Common symptoms of CAP include the following:

Breathing problems
Coughing that produces greenish or yellow sputum
A high fever that may be accompanied with sweating, chills, and uncontrollable shaking
Sharp or stabbing chest pain
Rapid, shallow breathing that is often painful

Documentation and Community-acquired pneumonia (CAP) ICD-10 CM coding

Code assignment for pneumonia depends on documentation of etiology or causative organism. The most common cause of CAP is streptococcus pneumonia which carries the label of pneumococcal pneumonia. However, coders cannot assume that CAP is pneumococcal pneumonia. Coders should not assume a causal relationship based solely on lab or radiology findings. All code assignment should be based on physician’s documentation. If a laboratory finding supports the selection of a more specific diagnosis then the physician should be queried to confirm the diagnosis selection.

Community-acquired pneumonia: Report code J18.9 (pneumonia, unspecified organism)
To report a more specific code, a physician must document a cause and effect relationship

Basic ICD-10 INFORMATION

World Health Organization (WHO) authorized the publication of the International Classification of Diseases External 10th Revision (ICD-10), which was implemented for mortality coding and classification from death certificates in the U.S. in 1999. The U.S. developed a Clinical Modification (ICD-10-CM) for medical diagnoses based on WHO’s ICD-10. This medical classification list is generated by the World Health Organization (WHO), and is used to help healthcare providers identify and code health conditions.