A08.4 - Viral intestinal infection, unspecified

Clinical Definition

Bacterial pneumonia is an infection of the lungs where bacteria multiply in the air sacs (alveoli), causing inflammation and fluid accumulation. This leads to breathing difficulties and systemic symptoms.

Documentation Requirements

• Causative Organism: Must specify type of bacteria (if known)

  • Through culture results

  • Through presumptive evidence

• Location/Laterality:

  • Which lung(s) affected (right, left, or bilateral)

  • Specific lobe involvement if known

• Acuity:

  • Onset (acute, chronic, or recurrent)

  • Duration of symptoms

• Severity:

  • Respiratory status

  • Need for supplemental oxygen

  • Ventilator requirements

• Associated Conditions:

  • Presence of effusion

  • Any underlying conditions

  • Complications if present

Common Synonyms

• Chest infection

• Lung infection

• Walking pneumonia (for milder cases)

• Bronchopneumonia

• "Double pneumonia" (when bilateral)

Coding Conflicts

• Excludes1: viral pneumonia

• Excludes1: aspiration pneumonia

• Cannot be coded with bronchitis in same anatomical location

Scribing.io Automation

The AI scribe automatically:

• Flags mention of positive cultures

• Identifies anatomical terms for location

• Captures severity indicators

• Links relevant lab values

• Highlights antibiotic choices

• Tags temporal markers for acuity

• Associates documented complications

• Cross-references with vital signs

For accuracy, doctors should verbalize "bacterial pneumonia" explicitly rather than just "pneumonia" when dictating.