Pneumonia, bacterial
| ICD10 Diagnosis | |
| Dx: | Pneumonia, bacterial |
| ICD10 code: | J15 |
| Pre-ICD10 counterpart: | CAP-Community Acquired Pneumonia, HAP-Hospital Acquired Pneumonia, VAP - Ventilator Associated Pneumonia |
| Charlson/ALERT Scale: | none |
| APACHE Como Component: | none |
| APACHE Acute Component: | 2019-0: Respiratory Infection |
| Start Date: | |
| Stop Date: | |
| External ICD10 Documentation | |
This diagnosis is a part of ICD10 collection.
Additional Info
Includes
- Postobstructive pneumonia due to bacterial infection of lung parenchyma secondary to bronchial obstruction that is often associated with lung cancer
VAP supersedes this code
- The diagnosis of VAP Pneumonia, ventilator-associated (VAP) supercedes this code.
HAP vs CAP
- For coding of hospital-acquired Pneumonia, bacterial, see Hospital-acquired pneumonia (HAP) in ICD10
- To decide about whether a CAP or HAP has occurred, requires clinical correlation.
- For example, sputum is almost never sterile -- bugs will always grow from it. It's even true that bronchoscopic lower respiratory samples are almost never sterile, which is why quantitative culture is used to interpret them. THUS, respiratory fluid that grows bugs cannot by itself be used to interpret the presence of pneumonia EXCEPT in the rare cases of bugs that are never pathogens in the respiratory system -- that list is mainly limited to: TB, Legionella, and Pneumocystis jiroveci. Thus, a (+) sputum culture can almost never by itself be used to identify the presence of a pneumonia. Instead, it's a combination of clinical signs such as fever, leukocytosis and new (or presumed new) CXR changes that helps to figure it out. Indeed, one can diagnose CAP or VAP in the absence of a (+)sputum culture in the right situation (e.g. patient has been on antibiotics for some reason prior).
In the context of COVID
Some special rules apply in the context of COVID infections, see COVID-19 (SARS-COV-2)#Coding of pneumonia in the context of COVID.
Possible Simultaneous Presence of Multiple Different Types of Pneumonia
- This usually refers to the situation where 1 type of pneumonia is "proven" and the clinical team is wondering about and presumptively treating the simultaneous presence of another type of organism. Examples:
- Proven influenza pneumonia and the question of a superimposed bacterial pneumonia as indicated by the patient also being placed on antibacterials.
- Proven COVID pneumonia and the question of a superimposed bacterial pneumonia as indicated by the patient also being placed on antibacterials.
- These are tricky because it is pretty common that before the primary (proven type) has been proven, that a patient is put on multiple types of antimicrobials -- e.g. it's flu season and patient comes in with a diffuse infiltrate and signs of infection, and the ED starts anti-viral + antibacterial drugs. What often happens is that in the next few days the team decides it was only influenza and stops the antibiotics. As it would be very very uncommon to treat a true bacterial pneumonia for <7 days, in THIS case we will use the guideline to code a bacterial pneumonia if the antibacterial agent was given for >4 days or the patient died before the 5th day of antimicrobials.
- As per our usual practice, we will consider a diagnosis as present if the clinical team thinks it's present and are treating it, with the exception (as directly above) that the team initially treated for the possible 2nd type of pneumonia but then decided it likely was NOT present and stopped those agents.
- Regarding use of Pneumonia, NOS versus any of Pneumonia, bacterial, Pneumonia, viral, Pneumonia, fungal/yeast
- Pneumonia, NOS should be used when there is a presumed pneumonia but the team is unsure what kind of organism is involved (bacteria, virus, fungus). So simply not having an organism from culture doesn't necessarily mean that Pneumonia, NOS should be used. If, for example, the team is assuming that it's a bacterial pneumonia (and treating it as such), but doesn't know which bacterium, then use Pneumonia, bacterial + Infectious organism, unknown
- this example highlights that Infectious organism, unknown is used when the the specific organism is unknown (this could be either not even knowing the TYPE of organism), while when the organism has been identified but it's not in our bug list, THEN use Bacteria, NOS, Virus, NOS or Fungus or yeast, NOS.
- Pneumonia, NOS should be used when there is a presumed pneumonia but the team is unsure what kind of organism is involved (bacteria, virus, fungus). So simply not having an organism from culture doesn't necessarily mean that Pneumonia, NOS should be used. If, for example, the team is assuming that it's a bacterial pneumonia (and treating it as such), but doesn't know which bacterium, then use Pneumonia, bacterial + Infectious organism, unknown
Guidelines for Recent Previous Pneumonia
- We have been reviewing our adjudication of VAP's using the CDC criteria. As a result we have tweaked some of our definitions and rules surrounding the coding of a PNA
- An important CDC guideline (Chapter 2 - Repeat Infection Timeframe (RIT)) is that if a pneumonia episode of any type is adjudicated to be present, then at least 14 days RIT must pass from its date of onset before another/different pneumonia episode (ie. VAP or HAP) can be identified as being present. This is the 14-day RIT and applies to both pneumonias present on infection AND hospital acquired pneumonias.
- This holds even if the pathogens are different, including viral infections
- This holds even if chest imaging shows infiltrates in different areas of the lungs
- A relevant manifestation of this is if a patient is admitted with a pneumonia (so it's a CAP), and is intubated, the earliest a VAP may occur is on hospital day#14.
- Day 1 of the RIT is the date of onset of the pneumonia.
- The 14-day RIT does NOT re-start if a second pathogen is cultured during the RIT.
- If a patient had any pneumonia previously during the same admission and then develops pneumonia again, meeting the VAP criteria, it is only a VAP if:
- (i) onset was at least 14 days after onset of the previous pneumonia, and
- (ii) has new and persistent OR progressive and persistent infiltrates. and
- (iii) there has been clinical resolution from the first episode, determined using best clinical judgement.
- It is possible to have subsequent pneumonia episodes with the same organism as the prior pneumonia. This can occur due to colonization of the airways with pathogens. If the same original organism is cultured with the subsequent pneumonia episode BUT after the 14-day RIT, then clinical judgement must be used to determine that the first pneumonia episode has clinically improved/resolved prior to the second subsequent episode. If the first pneumonia has not completely been resolved clinically, then you should NOT code it as a VAP.
- The same rules should apply for culture negative pneumonias. Clinical judgement will need to be used to ensure that the first pneumonia episode has resolved AND the VAP/HAP criteria are met AND the 14-day RIT has passed before a patient can have a subsequent pneumonia episode.
Example 1 - A patient is admitted with Strep pneumoniae pneumonia and intubated. On hospital day #7 (which is within the 14-day RIT) while intubated, there are clinical features of pneumonia and E. coli is cultured. This would be a single pneumonia episode with 2 pathogens - S. pneumoniae and E. coli, because the 14-day RIT has not passed.
Example 2 - An intubated patient develops a VAP with Stenotrophomonas maltophilia on hospital day 7. The patient is treated and clinically VAP resolves on hospital day 14. On hospital day 30 (which is past the 14-day RIT), the patient develops another VAP with new infiltrates, new clinical symptoms (which meet the pneumonia criteria) and Stenotrophomonas maltophilia is cultured again. This IS 2 separate VAP episodes, with the same organism.
Example 3 - An intubated patient is admitted and intubated with Strep pneumoniae pneumonia. Using best clinical judgement, the patient does NOT have clinical resolution of the first pneumonia, and has persistent infiltrates. On hospital day 16 (which is past the 14-day RIT), Strep pneumoniae is cultured again. This is NOT a separate VAP episode with the same organism.
Example 4 - An intubated patient is admitted and intubated with culture negative pneumonia. Using best clinical judgement, the patient does NOT have clinical resolution of the first pneumonia (ie. persistent leukocytosis, fevers, purulent secretions) and has persistent infiltrates. On day 16 (which is past the 14-day RIT), E. coli is cultured. This would NOT be a separate VAP because the first pneumonia did not appear to be resolved. IF however the patient DID have resolution of the first pneumonia using best clinical judgement, then develops progressive and persistent infiltrates and meets the other VAP criteria on day 16, then this IS a VAP.
Alternate ICD10s to consider coding instead or in addition
| Pneumonia codes: |
Candidate Combined ICD10 codes
- Combine with Nosocomial infection, NOS to make bacterial hospital-acquired pneumonia
Infections
Infections in ICD10 have combined coding requirements for some of their pathogens. Any that have antibiotic resistances would store those as Combined ICD10 codes as well. If the infection is acquired in the hospital, see Nosocomial infection, NOS. See Lab and culture reports for confirmation and details about tests. See Infections in ICD10 for more general info.
Possible Simultaneous Presence of Multiple Different Types of Infection in a Single Site
- This refers to the situation where there may be simultaneous infection with multiple types of organisms -- e.g. 2 of bacteria, virus, fungus. While a classic example is a proven viral pneumonia (e.g. influenza) with a suspected/possible bacterial pneumonia superimposed, this kind of thing can occur in places other than the lungs, e.g. meningitis.
- The "signature" of this is typically the patient being treated simultaneously with antimicrobial agents for multiple types of organisms. BUT don't confuse this with there being infections at DIFFERENT body sites.
- As per our usual practice, we will consider a diagnosis as present if the clinical team thinks it's present and are treating it, with the exception that the team initially treated for the possible 2nd type of infection but then decided it likely was NOT present and stopped those agents.
- And remember that Infectious organism, unknown is used when the the specific organism is unknown (this could be not knowing the TYPE of organism, or suspecting the type but not having identified the specific organism of that type), while when the organism has been identified but it's not in our bug list, THEN use Bacteria, NOS, Virus, NOS or Fungus or yeast, NOS.
Attribution of infections
Related CCI Codes
Data Integrity Checks (automatic list)
| App | Status | |
|---|---|---|
| Query check ICD10 Inf Infection req Pathogen must have one | CCMDB.accdb | implemented |
| Query Check Inf Pathogens must have Infection requiring pathogen or Potential Infection | CCMDB.accdb | implemented |
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