Z95.1 - Presence of aortocoronary bypass graft

Clinical Definition

A pediatric pneumonia infection is an inflammatory condition of the lungs specifically occurring in children where air sacs become filled with fluid or pus. This acute respiratory infection may be caused by viruses, bacteria, or other microorganisms.

Documentation Requirements

• Age of patient must be documented (<18 years)

• Causative organism if identified:

  • Viral

  • Bacterial (specify organism if known)

  • Fungal

  • Aspiration

• Location/Laterality:

  • Right lung

  • Left lung

  • Bilateral

  • Specific lobe(s) affected

• Severity indicators:

  • Oxygen requirement

  • Respiratory distress level

  • Need for hospitalization

• Associated conditions:

  • Pleural effusion

  • Respiratory failure

  • Sepsis if present

Common Synonyms

• "Chest infection"

• "Lung infection"

• "Bronchopneumonia"

• "Chest cold"

• "Walking pneumonia" (in milder cases)

Coding Conflicts

Excludes1:

• Congenital pneumonia (P23.-)

• Pneumonia due to cystic fibrosis (E84.-)

Excludes2:

• Pneumonitis due to aspiration (J69.-)

• Interstitial pneumonia (J84.9)

Scribing.io Automation

Our AI scribe automatically identifies:

• Age indicators in patient demographics

• Documented infectious agents from lab results

• Radiological findings mentioning consolidation or infiltrates

• Vital signs indicating respiratory distress

• Treatment plans including antibiotics or antivirals

• Oxygen requirements and respiratory support measures

When these elements are detected, the AI tags them for CDI review and suggests appropriate pediatric pneumonia codes based on the documented specificity.