J15.212 ICD-10-CM Code: Pneumonia due to Methicillin resistant Staphylococcus aureus

Code

J15.212

Description

Pneumonia due to Methicillin resistant Staphylococcus aureus

HCC (V28)

HCC 282 — Aspiration and Specified Bacterial Pneumonias

RAF reference coefficient

0.440

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 J15.212 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →

MEAT review for J15.212

What This Code Means

HCC Buddy maintains structured V28 and V24 mapping, source-labeled coefficient references, and MEAT documentation criteria for J15.212 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

• •Verify susceptibility testing confirms methicillin resistance before coding
• •MRSA pneumonia often requires specialized antibiotic therapy and may indicate healthcare-associated infection

Clinical Significance

Pneumonia due to Methicillin-resistant Staphylococcus aureus (MRSA) is a significant bacterial respiratory infection that increases morbidity, particularly in elderly and immunocompromised patients. MRSA pneumonia carries significant treatment challenges due to antibiotic resistance, requiring vancomycin or linezolid therapy, and is associated with higher mortality and longer hospital stays than MSSA pneumonia. Accurate organism identification impacts treatment decisions, infection control measures, and risk stratification.

Documentation Requirements

• ✓Documentation of pneumonia diagnosis with causative organism identified as Methicillin-resistant Staphylococcus aureus (MRSA)
• ✓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)
• ✓Susceptibility testing results documenting methicillin resistance or susceptibility

Commonly Confused Codes

• •J15.211: MSSA pneumonia; susceptibility is the critical distinction: verify resistance testing
• •J15.20: Staphylococcal pneumonia, unspecified; use only when resistance status is unknown
• •J15.29: Pneumonia due to other staphylococcus; use for non-aureus species
• •J18.9: Pneumonia, unspecified organism; do not use when the causative organism has been identified

Child Codes