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J13 ICD-10-CM Code: Pneumonia due to Streptococcus pneumoniae

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FY 2026 Apr update / Diseases of the respiratory system (J00-J99) / Influenza and pneumonia (J09-J18)

J13

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Pneumonia due to Streptococcus pneumoniae

Pneumonia caused by Streptococcus pneumoniae bacteria, a common cause of bacterial pneumonia.

Buddy the Bee presenting code insight

Buddy Insight

Pneumonia due to Streptococcus pneumoniae (pneumococcus) is a significant bacterial respiratory infection that increases morbidity, particularly in elderly and immunocompromised patients.

CMS-HCC V28

N/A

—

Not mapped

CMS-HCC V24

HCC 115

RAF 0.130

ACA/HHS

N/A

—

Not mapped

ESRD/PACE

HCC 115

RAF 0.030

RXHCC

N/A

—

Not mapped

Code Book Path

Official
J1Influenza and pneumonia (J09-J18)
J13Pneumonia due to Streptococcus pneumoniae

Inclusion Terms

Official
  • Bronchopneumonia due to S. pneumoniae

Excludes 2

Official

ICD-10-CM does not list Excludes 2 notes for J13 in this effective period.

Related Child Codes

Official

ICD-10-CM does not list child codes under J13 for this display context.

Includes

Official

ICD-10-CM does not list Includes notes for J13 in this effective period.

Excludes 1

Official
  • congenital pneumonia due to S. pneumoniae (P23.6)
  • lobar pneumonia, unspecified organism (J18.1)
  • pneumonia due to other streptococci (J15.3-J15.4)

Code First

Official
  • , if applicable, associated influenza (J09.X1, J10.0-, J11.0-)

Use Additional

Official

ICD-10-CM does not list Use Additional Code instructions for J13 in this effective period.

Code Also

Official
  • , if applicable, any associated condition such as:
  • abscess (J85.1)
  • aspiration pneumonia (J69.-)

Buddy Documentation Tip

HCC Buddy guidance
Documentation of pneumonia diagnosis with causative organism identified as Streptococcus pneumoniae (pneumococcus)
Chest imaging (X-ray or CT) findings consistent with pneumonia
Clinical signs and symptoms documented (fever, cough, dyspnea, sputum production)
Culture, sputum, or molecular testing results confirming the specific organism

MEAT Support

HCC Buddy guidance
Documentation of pneumonia diagnosis with causative organism identified as Streptococcus pneumoniae (pneumococcus)
Chest imaging (X-ray or CT) findings consistent with pneumonia
Clinical signs and symptoms documented (fever, cough, dyspnea, sputum production)
Culture, sputum, or molecular testing results confirming the specific organism

Audit Caution

HCC Buddy guidance
Coding a specific organism pneumonia without supporting culture, sputum, or molecular test results — empiric treatment alone does not confirm the organism
Using unspecified pneumonia codes (J18.9) when the causative organism has been identified through testing
Failing to distinguish between pneumonia and lower respiratory tract infections such as acute bronchitis — pneumonia involves lung parenchyma infiltrate
Not coding associated conditions such as sepsis (A41.x), respiratory failure (J96.x), or acute respiratory distress syndrome (J80) when documented

Common Mistakes

HCC Buddy guidance
J15.0-J15.29 — Other specified bacterial pneumonias; ensure culture confirms pneumococcus specifically
J18.1 — Lobar pneumonia, unspecified organism; if organism is not identified, this more general code applies
J14 — Pneumonia due to Hemophilus influenzae; different organism despite similar clinical presentation
J15.4 — Pneumonia due to other streptococci; pneumococcus is S. pneumoniae specifically, not other streptococcal species

Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →

Is J13 an HCC code?

Yes. J13 maps to Pneumococcal Pneumonia, Empyema, Lung Abscess under the V24 model but is not retained in V28.

Code
J13
Description
Pneumonia due to Streptococcus pneumoniae
HCC (V28)
No CMS-HCC V28 mapping
RAF
—
Billable
Yes
Payment year
2026

HCC Category Mapping

V24HCC 115, Pneumococcal Pneumonia, Empyema, Lung Abscess
0.130
ESRDHCC 115, Pneumococcal Pneumonia, Empyema, Lung Abscess
0.030

Each model's RAF is its CMS base weight for that model's standard population, so weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.

Work J13 in the Code Book — tabular path, V28 RAF, and MEAT checklist →

MEAT Criteria for J13

For J13 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically, it has to be re-documented and supported each calendar year.

  • MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
  • EEvaluate: test results, medication response, or physical findings reviewed by the provider
  • AAssess: explicit mention in the assessment or plan with acknowledgment of status
  • TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis

Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed J13 during that encounter, not just copy-forwarded from a problem list.

Coder workflow notes

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What This Code Means

J13 is the ICD-10-CM diagnosis code for pneumonia due to streptococcus pneumoniae. Pneumonia caused by Streptococcus pneumoniae bacteria, a common cause of bacterial pneumonia. J13 sits in the ICD-10-CM chapter for diseases of the respiratory system (j00-j99), within the section covering influenza and pneumonia (j09-j18).

Under the older CMS-HCC V24 model, J13 maps to Pneumococcal Pneumonia, Empyema, Lung Abscess (HCC 115) with a community, non-dual, aged base RAF weight of 0.130. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.

No additional characters needed; this is a complete code. Because J13 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.

HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for J13 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

  • •No additional characters needed; this is a complete code
  • •Verify culture or test results confirm pneumococcal infection before coding

Clinical Significance

Pneumonia due to Streptococcus pneumoniae (pneumococcus) is a significant bacterial respiratory infection that increases morbidity, particularly in elderly and immunocompromised patients. This organism is a leading cause of community-acquired pneumonia and carries specific vaccination and treatment protocol implications. Accurate organism identification impacts treatment decisions, infection control measures, and risk stratification.

Documentation Requirements

  • ✓Documentation of pneumonia diagnosis with causative organism identified as Streptococcus pneumoniae (pneumococcus)
  • ✓Chest imaging (X-ray or CT) findings consistent with pneumonia
  • ✓Clinical signs and symptoms documented (fever, cough, dyspnea, sputum production)
  • ✓Culture, sputum, or molecular testing results confirming the specific organism
  • ✓Antibiotic therapy prescribed and documented
  • ✓Severity assessment (need for oxygen, hospitalization, intensive care)

Excludes 1, Do NOT code together

  • congenital pneumonia due to S. pneumoniae (P23.6)
  • lobar pneumonia, unspecified organism (J18.1)
  • pneumonia due to other streptococci (J15.3-J15.4)

Code First

Code Also

  • , if applicable, any associated condition such as:
  • abscess (J85.1)
  • aspiration pneumonia (J69.-)

Commonly Confused Codes

  • •J15.0-J15.29: Other specified bacterial pneumonias; ensure culture confirms pneumococcus specifically
  • •J18.1: Lobar pneumonia, unspecified organism; if organism is not identified, this more general code applies
  • •J14: Pneumonia due to Hemophilus influenzae; different organism despite similar clinical presentation
  • •J15.4: Pneumonia due to other streptococci; pneumococcus is S. pneumoniae specifically, not other streptococcal species

Code Hierarchy

└J13Pneumonia due to Streptococcus pneumoniae
└J13Pneumonia due to Streptococcus pneumoniae

Because J13 maps to a payment HCC, the documentation must also satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's risk adjustment score.

More on J13

Referenced in blog posts

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