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J86.9 ICD-10-CM Code: Pyothorax without fistula

J86.9 maps to CMS-HCC V28 283. A source-labeled RAF reference is available. Confirm the documented diagnosis and applicable coding requirements. MEAT criteria · RAF Calculator · free HCC coding tools

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Code lookupJ86.9

FY 2026 Apr update / Diseases of the respiratory system (J00-J99) / Suppurative and necrotic conditions of the lower respiratory tract (J85-J86)

J86.9

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

Pyothorax without fistula

A collection of pus in the space around the lungs without an abnormal opening or tunnel connecting to the outside.

Buddy the Bee presenting code insight

Buddy Insight

Pyothorax without fistula (empyema) is a collection of infected fluid or pus in the pleural space, typically complicating pneumonia, thoracic surgery, or esophageal perforation.

OverviewRisk ModelsCode BookDocumentationAuditNotesEdition comparison

CMS-HCC V28

HCC 283

Coefficient HCC 283: 0.204 (Community Non-Dual Aged (CNA))

CMS-HCC V24

Historical

Historical

Not used for CY2026 payment

ACA/HHS

HCC 163

Code-level coefficient reference

ESRD/PACE

HCC 115

Code-level coefficient reference

RXHCC

N/A

—

Not mapped

Code Book Path

Official
J86PyothoraxJ86.9Pyothorax without fistula

Inclusion Terms

Official
  • Abscess of pleura
  • Abscess of thorax
  • Empyema (chest) (lung) (pleura)
  • Fibrinopurulent pleurisy
  • Purulent pleurisy
  • Pyopneumothorax
  • Septic pleurisy
  • Seropurulent pleurisy
  • Suppurative pleurisy

Excludes 2

Official
  • certain conditions originating in the perinatal period (P04-P96)Inherited from J00-J99
  • certain infectious and parasitic diseases (A00-B99)Inherited from J00-J99
  • complications of pregnancy, childbirth and the puerperium (O00-O9A)Inherited from J00-J99
  • congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)Inherited from J00-J99
  • endocrine, nutritional and metabolic diseases (E00-E88)Inherited from J00-J99
  • injury, poisoning and certain other consequences of external causes (S00-T88)Inherited from J00-J99
  • neoplasms (C00-D49)Inherited from J00-J99
  • smoke inhalation (T59.81-)Inherited from J00-J99
  • symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)Inherited from J00-J99

Related Codes

Official
J86.0Pyothorax with fistula

Includes

Official

No Includes notes are included in this display for J86.9. Check the code and parent instructions in the Code Book.

Excludes 1

Official
  • abscess of lung (J85.-)Inherited from J86
  • pyothorax due to tuberculosis (A15.6)Inherited from J86

Code First

Official

No Code First sequencing instructions are included in this display for J86.9. Check the code and parent instructions in the Code Book.

Use Additional

Official
  • code, where applicable, to identify:Inherited from J00-J99, J86
  • exposure to environmental tobacco smoke (Z77.22)Inherited from J00-J99, J86
  • exposure to tobacco smoke in the perinatal period (P96.81)Inherited from J00-J99, J86
  • history of tobacco dependence (Z87.891)Inherited from J00-J99, J86
  • occupational exposure to environmental tobacco smoke (Z57.31)Inherited from J00-J99, J86
  • tobacco dependence (F17.-)Inherited from J00-J99, J86
  • tobacco use (Z72.0)Inherited from J00-J99, J86
  • code (B95-B97) to identify infectious agent.Inherited from J00-J99, J86

Code Also

Official

No Code Also instructions are included in this display for J86.9. Check the code and parent instructions in the Code Book.

Buddy Documentation Tip

HCC Buddy guidance
Imaging confirming pleural fluid collection with characteristics of empyema (loculation, pleural thickening)
Pleural fluid analysis showing purulent fluid, positive cultures, or biochemical evidence of infection (low pH, low glucose, high LDH)
Documentation confirming no fistula is present (if fistula present, use J86.0)
Causative organism identification if available

MEAT Support

HCC Buddy guidance
Imaging confirming pleural fluid collection with characteristics of empyema (loculation, pleural thickening)
Pleural fluid analysis showing purulent fluid, positive cultures, or biochemical evidence of infection (low pH, low glucose, high LDH)
Documentation confirming no fistula is present (if fistula present, use J86.0)
Causative organism identification if available

Audit Caution

HCC Buddy guidance
Confusing empyema (infected pleural fluid) with simple parapneumonic effusion (non-infected reactive effusion adjacent to pneumonia)
Using the unspecified pleural effusion code (J90) when pleural fluid is documented as infected or purulent
Failing to check for fistula presence — if fistula exists, J86.0 should be used instead
Not coding the underlying cause (pneumonia, post-surgical complication) separately

Common Mistakes

HCC Buddy guidance
J86.0 — Pyothorax with fistula is used when an abnormal communication accompanies the empyema
J90 — Pleural effusion not elsewhere classified is for non-infected effusions
J91.0 — Malignant pleural effusion is cancer-related, not infectious
J85.2 — Abscess of lung without pneumonia is infection in the lung parenchyma, not the pleural space

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 J86.9 an HCC code?

Yes. J86.9 (Pyothorax without fistula) maps to HCC 283, Empyema, Lung Abscess under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.204. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes. It is billable for payment year 2026.

Coder answer: J86.9 is billable and maps to V28 HCC 283, Empyema, Lung Abscess. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.

Code
J86.9
Description
Pyothorax without fistula
HCC (V28)
HCC 283 — Empyema, Lung Abscess
RAF reference coefficient
0.204
Billable
Yes
Payment year
2026

HCC Category Mapping

V28HCC 283, Empyema, Lung Abscess
0.204
ESRDHCC 115, Pneumococcal Pneumonia/Empyema/Lung Abscess
Not separately weighted

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 J86.9 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →

MEAT review for J86.9

For J86.9, 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

J86.9 is the ICD-10-CM diagnosis code for pyothorax without fistula. A collection of pus in the space around the lungs without an abnormal opening or tunnel connecting to the outside. J86.9 sits in the ICD-10-CM chapter for diseases of the respiratory system (j00-j99), within the section covering suppurative and necrotic conditions of the lower respiratory tract (j85-j86).

Under the CMS-HCC V28 risk adjustment model, J86.9 maps to Empyema, Lung Abscess (HCC 283) with a source-labeled community, non-dual, aged reference coefficient of 0.204. For CY2026 non-PACE Medicare Advantage, CMS uses 100% of the 2024 CMS-HCC model (V28). PACE uses a separate model blend. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes.

Verify whether a fistula is present; if documented, use J86.0 instead. For J86.9, 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. 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, source-labeled coefficient references, and MEAT documentation criteria for J86.9 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

  • •Verify whether a fistula is present; if documented, use J86.0 instead
  • •This code indicates infection/inflammation of the pleural space requiring drainage and antibiotics

Clinical Significance

Pyothorax without fistula (empyema) is a collection of infected fluid or pus in the pleural space, typically complicating pneumonia, thoracic surgery, or esophageal perforation. This condition requires chest tube drainage, prolonged antibiotic therapy, and may require surgical decortication. It represents significant morbidity and resource utilization beyond simple pleural effusion.

Documentation Requirements

  • ✓Imaging confirming pleural fluid collection with characteristics of empyema (loculation, pleural thickening)
  • ✓Pleural fluid analysis showing purulent fluid, positive cultures, or biochemical evidence of infection (low pH, low glucose, high LDH)
  • ✓Documentation confirming no fistula is present (if fistula present, use J86.0)
  • ✓Causative organism identification if available
  • ✓Treatment plan including drainage and antibiotic regimen

Commonly Confused Codes

  • •J86.0: Pyothorax with fistula is used when an abnormal communication accompanies the empyema
  • •J90: Pleural effusion not elsewhere classified is for non-infected effusions
  • •J91.0: Malignant pleural effusion is cancer-related, not infectious
  • •J85.2: Abscess of lung without pneumonia is infection in the lung parenchyma, not the pleural space

Child Codes

J86.0Pyothorax with fistula
HCC 283
J86.9Pyothorax without fistula
HCC 283

Code Hierarchy

└J86Pyothorax└J86.9Pyothorax without fistula
└J86.9Pyothorax without fistula

Also searched as

  • J86 9
  • J869

For J86.9, 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.

J86.9 maps to CMS-HCC V28 category 283, Empyema, Lung Abscess. See the ICD-10 to HCC mapping hub for how the V28 crosswalk works. The mapping identifies a payment HCC category for J86.9. Review its source-labeled HCC coefficient above, check the RAF Calculator with complete member context for CMS-HCC V28 PY2026, and confirm the documentation the chart needs before the code is submitted. HCC Buddy shows no RAF score unless every required source and calculation check passes.

Work J86.9 in HCC Buddy

Open J86.9 in the Code Book for the full Index-to-Tabular path, MEAT checklist, and V28 HCC mapping, or in the Encoder to code from a keyword search. Pro includes 7 days to try everything, no card required.

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