2025 ICD-10-CM code J95.851
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Respiratory System Disorders - Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified Diseases of the respiratory system (J00-J99) Feed
Ventilator-associated pneumonia (VAP) is a lung infection that occurs in patients requiring mechanical ventilation.
Modifiers may be applicable depending on the circumstances of the procedure and the healthcare setting. Consult the CMS National Coverage Determinations and local payer guidelines.
Medical necessity for coding J95.851 is established by the presence of clinical symptoms (fever, cough, purulent sputum, increased respiratory distress), radiological evidence of pneumonia (chest X-ray or CT scan), and confirmation of the infection through positive microbiological cultures.The documentation must support the diagnosis, confirming the causative organism, and justify the necessity of mechanical ventilation.
The clinical responsibility for managing VAP rests with the pulmonologist or intensivist, who will oversee the diagnosis, treatment, and monitoring of the patient's respiratory status. The infectious disease specialist plays a crucial role in guiding antibiotic therapy, based on the results of the microbiological tests.
- Diseases of the respiratory system (J00-J99)
- J95-J95.89 (Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified)
In simple words: Ventilator-associated pneumonia (VAP) is a lung infection that can happen when a person is on a breathing machine. It's a serious infection that needs treatment with antibiotics or antifungal medications.
Ventilator-associated pneumonia (VAP) is a type of pneumonia that develops in individuals who are receiving mechanical ventilation.It's a serious complication characterized by inflammation and infection of the lung tissue, often caused by bacteria, fungi, or viruses.The infection typically arises from microorganisms entering the airways via the endotracheal tube or ventilator circuit.Clinical manifestations include fever, cough, purulent sputum, and increased respiratory distress.Diagnosis relies on clinical presentation, imaging (chest X-ray or CT scan), and microbiological analysis of respiratory samples. Treatment involves broad-spectrum antibiotics or antifungals guided by culture results, along with supportive care such as oxygen therapy and airway management. Use additional code to identify the organism if known (B95.-, B96.-, B97.-). Excludes1: ventilator lung in newborn (P27.8). Excludes2: aspiration pneumonia (J69.-), subcutaneous emphysema resulting from a procedure (T81.82), hypostatic pneumonia (J18.2), pulmonary manifestations due to radiation (J70.0-J70.1).
Example 1: A 70-year-old male patient admitted for a hip fracture develops VAP 5 days postoperatively after endotracheal intubation.The patient exhibits fever, productive cough with purulent sputum, and increased respiratory distress.Chest X-ray confirms the presence of bilateral infiltrates.Blood cultures and sputum cultures are taken. The physician prescribes broad-spectrum antibiotics pending results of the cultures., A 65-year-old female with severe COPD requiring mechanical ventilation in the ICU for acute respiratory failure develops VAP after 10 days of intubation. The patient's respiratory status worsens, exhibiting increased work of breathing, hypoxemia, and altered mental status.Broad-spectrum antibiotics are started immediately. Bronchoscopy is performed to collect samples for culture, which confirms Pseudomonas aeruginosa infection.The antibiotic regimen is adjusted accordingly., A 55-year-old male patient undergoing abdominal surgery is intubated after prolonged anesthesia. Postoperatively, he develops a fever and a productive cough with green-colored sputum. He is diagnosed with VAP based on chest X-ray findings and sputum culture that confirms Klebsiella pneumoniae infection.The treatment involves targeted antibiotics based on the culture results and supportive respiratory care.
Detailed physician documentation is crucial, including the patient's respiratory status before, during, and after intubation.Thorough documentation of the timeline of symptom onset, physical examination findings, chest X-ray results, microbiology reports (culture and sensitivity results), and the chosen antibiotic regimen is essential.Any changes in respiratory support measures and the patient's response to treatment should also be documented.
** VAP is a serious condition with high morbidity and mortality rates.Prompt diagnosis and appropriate antimicrobial therapy are critical for optimal patient outcomes.Careful attention to infection control measures is essential in preventing VAP in mechanically ventilated patients.
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- Payment Status: Active
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- Specialties:Pulmonology, Critical Care Medicine, Infectious Disease
- Place of Service:Inpatient Hospital, Intensive Care Unit (ICU)