J18.9
Pneumonia, unspecified organism
Diseases of the respiratory system Billable
Quick Reference
Clinical or radiographic pneumonia without identified causative organism
Clinical Information
When to Use This Code
Clinical or radiographic pneumonia without identified causative organism
Common Clinical Scenarios
- Community-acquired pneumonia (CAP) without culture
- Chest X-ray showing infiltrate with clinical symptoms
- Empiric antibiotic treatment for pneumonia
- Healthcare-associated pneumonia
Documentation Requirements
- Document chest imaging findings (infiltrate, consolidation)
- Record clinical signs: fever, cough, dyspnea, hypoxia
- Note if community-acquired vs. healthcare-associated
- Document antibiotic therapy and response
Coding Guidelines
Inclusion Terms
These terms are included in this code:
Pneumonia NOSCommunity-acquired pneumoniaLung infiltrate with infection
Exclusion Terms
Do NOT use this code for:
- Aspiration pneumonia (J69.-)
- Viral pneumonia (J12.-)
- Bacterial pneumonia with identified organism (J13-J16)
- COVID-19 pneumonia (U07.1)
Coding Notes
Use specific organism codes when culture positive
Document severity for risk stratification (PSI or CURB-65 score)
Add codes for complications (sepsis, respiratory failure)
Related ICD-10 Codes
Consider these related codes based on patient presentation:
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Code
J18.9
Category
Diseases of the respiratory system
Billable Status
Billable
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