J13 ICD-10-CM Code: Pneumonia due to Streptococcus pneumoniae
J13 is not a CMS-HCC payment code. MEAT criteria · RAF Calculator · HCC coding software
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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 guidancePneumonia due to Streptococcus pneumoniae
Pneumonia caused by Streptococcus pneumoniae bacteria, a common cause of bacterial pneumonia.
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
HistoricalHistorical
Not used for CY2026 payment
ACA/HHS
N/A—
Not mapped
ESRD/PACE
MappedHCC 115
Code-level coefficient reference
RXHCC
N/A—
Not mapped
Code Book Path
Inclusion Terms
Official- Bronchopneumonia due to S. pneumoniae
Excludes 2
Official- certain conditions originating in the perinatal period (P04-P96)Inherited from J00-J99, J09-J18
- certain infectious and parasitic diseases (A00-B99)Inherited from J00-J99, J09-J18
- complications of pregnancy, childbirth and the puerperium (O00-O9A)Inherited from J00-J99, J09-J18
- congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)Inherited from J00-J99, J09-J18
- endocrine, nutritional and metabolic diseases (E00-E88)Inherited from J00-J99, J09-J18
- injury, poisoning and certain other consequences of external causes (S00-T88)Inherited from J00-J99, J09-J18
- neoplasms (C00-D49)Inherited from J00-J99, J09-J18
- smoke inhalation (T59.81-)Inherited from J00-J99, J09-J18
- symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)Inherited from J00-J99, J09-J18
- allergic or eosinophilic pneumonia (J82)Inherited from J00-J99, J09-J18
- aspiration pneumonia NOS (J69.0)Inherited from J00-J99, J09-J18
- meconium pneumonia (P24.01)Inherited from J00-J99, J09-J18
- neonatal aspiration pneumonia (P24.-)Inherited from J00-J99, J09-J18
- pneumonia due to solids and liquids (J69.-)Inherited from J00-J99, J09-J18
- congenital pneumonia (P23.9)Inherited from J00-J99, J09-J18
- lipid pneumonia (J69.1)Inherited from J00-J99, J09-J18
- rheumatic pneumonia (I00)Inherited from J00-J99, J09-J18
- ventilator associated pneumonia (J95.851)Inherited from J00-J99, J09-J18
Related Codes
No related codes are included in this display for J13. Check the Code Book for the complete code path.
Includes
OfficialNo Includes notes are included in this display for J13. Check the code and parent instructions in the Code Book.
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- code, where applicable, to identify:Inherited from J00-J99, J09-J18
- exposure to environmental tobacco smoke (Z77.22)Inherited from J00-J99, J09-J18
- exposure to tobacco smoke in the perinatal period (P96.81)Inherited from J00-J99, J09-J18
- history of tobacco dependence (Z87.891)Inherited from J00-J99, J09-J18
- occupational exposure to environmental tobacco smoke (Z57.31)Inherited from J00-J99, J09-J18
- tobacco dependence (F17.-)Inherited from J00-J99, J09-J18
- tobacco use (Z72.0)Inherited from J00-J99, J09-J18
- code, if applicable, to identify resistance to antimicrobial drugs (Z16.-)Inherited from J00-J99, J09-J18
Code Also
Official- , if applicable, any associated condition such as:
- abscess (J85.1)
- aspiration pneumonia (J69.-)
Buddy Documentation Tip
MEAT Support
Audit Caution
Common Mistakes
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?
J13 has no mapping under the current CMS-HCC V28 community payment model. J13 has a separate mapping under the CMS-HCC ESRD model (HCC 115 (Pneumococcal Pneumonia/Empyema/Lung Abscess)); the applicable result needs member context.
- Code
- J13
- Description
- Pneumonia due to Streptococcus pneumoniae
- HCC (V28)
- No CMS-HCC V28 mapping
- RAF reference coefficient
- —
- Billable
- Yes
- Payment year
- 2026
HCC Category Mapping
These are source-labeled model coefficients, not member totals. A category may still be removed by hierarchy or model cleanup rules. 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 context, hierarchy and cleanup rules, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains available for historical review.
Work J13 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →
MEAT review for J13
For J13, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.
- 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
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).
J13 has no mapping under the current CMS-HCC V28 community payment model. J13 has a separate mapping under the CMS-HCC ESRD model (HCC 115 (Pneumococcal Pneumonia/Empyema/Lung Abscess)); the applicable result needs member context. Do not assign V28 risk adjustment value from this page; verify the applicable model and payment year before using this code for risk adjustment.
No additional characters needed; this is a complete code.
HCC Buddy maintains structured V28 and V24 mapping, source-labeled coefficient references, 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
Code Also
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