CAP-Community Acquired Pneumonia: Difference between revisions

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{{DX tag | Infection | [[:Category: Medical Problem | Medical Problem]] | [[:Category: Pneumonia | Pneumonia]] | PNEUMONIA-CAP | [[3700 - CAP-Community Acquired Pneumonia]] | No | 0 |CC & Med |  Currently Collected | | |}}
{{PreICD10 dx | NewDxArticle = Aspiration pneumonitis}}
{{PreICD10 dx | NewDxArticle = Pneumonia, bacterial }}
{{PreICD10 dx | NewDxArticle = SARS (severe acute respiratory syndrome) }}  


=={{Data Integrity Rules}}==
{{DX tag | Infection | Medical Problem | [[:Category: Pneumonia|Pneumonia]] | PNEUMONIA-CAP | 3700 - CAP-Community Acquired Pneumonia | No | 0 |CC & Med |  Currently Collected | | |}}
A CAP is not allowed in acquired/complications. While in hospital a patient can acquire a [[VAP]] if ventilated or a [[HAP]] but not CAP.
*CAP is coded if the pneumonia is evident within the first 48 hours of admission, this includes patients where the doctor is calling it a pneumonia and are treating it with antibiotics with or without a positive culture. If the doctor is calling it an aspiration pneumonia, this is a misnomer, it should be called aspiration pneumonitis.  Pneumonia is an infectious process and while aspiration can pre-dispose someone to pneumonia, it should not be called pneumonia until there is clear evidence of such (organism isolated, CXR worsening infiltrates, antibiotics started, increased oxygen requirements, etc.) This is per Dr. Garland. --[[User:LKolesar|LKolesar]] 11:27, 2013 March 7 (EST)
Rule added in version ver 2012-04-12.
*In the setting of a known aspiration event:
==Question==
Use [[Pneumonitis 2nd Chemical Aspiration]] (3019) instead of utilizing the aspiration subcode located in the pathogen section.  (per Dr.Garland)
*Regarding this rule not allowing a CAP diagnosis in the complications: If a patient aspirates in the community it is coded as CAP-aspiration.  When the cultures come back a few days later as positive, Dr. Roberts has told us to code CAP-the organism in the acquired/complication section in order to capture the organism.  Trish, do you want us to change this practice and only put in the aspiration then and to disregard which organism is later cultured??  Please let us know.--[[User:LKolesar|LKolesar]] 08:33, 2012 April 17 (CDT)
*code CAP-with organism in the admit diagnosis section if a pathogen IS isolated from a culture drawn within 48 hour or less of admission.  If this happens you can still leave the pneumonitis 2nd chemical aspiration if there is room for both.
**I thought if the culture came back positive within the 48 hour range of admission you automatically changed your admit asp pneumonia to Cap with culture? - this is correct.[[User:TOstryzniuk|Trish Ostryzniuk]] 16:28, 2012 May 15 (CDT)
*Note a CAP can be coded with or without an aspiration. Also, pneumonitis 2nd aspiration can be coded without coding a pneumonia.
**We do not have any guideline therefore this needs to be decided.  Trish is going to ask the doctors if capturing aspiration is more important or if the organisms are more important if only one is to be entered.  --[[User:LKolesar|LKolesar]] 09:09, 2012 April 19 (CDT)
***I understood that if we code CAP-aspiration as an admit Dx and if the culture comes back positive;  we are to then to code it as HAP in the acquired DX (ie acquired: HAP-with the bug).  I am trying to find the minutes from the team meeting when Dr. Roberts stated this and will copy if able to locate. [[User:Mlaporte|Mlaporte]] 13:32, 2012 May 1 (CDT)-
***Trish, what is the outcome of your discussion with the doctors on this issue?? I have outstanding patients that I do not know how to code their diagnosis properly and Julie sent me an audit of all my CAP aspiration patients but I still don't know your decision on how to code these so the audit is sitting on my desk. Please respond asap. Thanks!--[[User:LKolesar|LKolesar]] 08:36, 2012 May 10 (CDT)


==Question==
If pathogen IS isolated from a culture drawn greater than 48 hours AFTER admission, code as a [[HAP]] with organism which is coded in the complication section.  
{{Discussion}}
**Note: a sterile aspiration can become superinfected while in hospital.  
*When patients come in with COPD exacerbation and are put on oral antibiotics, do other collectors in city code as admitted with a CAP along with the COPD? 
**at HSC on wards, it is not the norm to see the written DX of CAP along with COPD exacerbation, yet or patient is prescribed antibiotics. Pat codes a CAP if on IV antibiotic but if prescribe oral antibiotics and not written DX of CAP, then she will not code as CAP. Pat says her interpretation is that it could it upper airway infection or even bronchitis, but Dr. has not committed to either DX.    What do others do?  Thank you for feedback-[[User:TOstryzniuk|Trish Ostryzniuk]] 14:25, 2012 April 13 (CDT) & [[User: PStein|Pat Stein]]
*If patient is treated with antibiotics I code both COPD exascerbation and CAP because quite often their CXR cannot rule out an underlying pneumonia so the physicians will treat on spec (as they often chart it this way in the IPN).--[[User:CMarks|CMarks]] 14:50, 2012 April 16 (CDT)
*I only code a CAP if the doctors are calling it a pneumonia. If anyone wants to research CAP's they should know that all COPD exacerbations are potentially a pneumonia.--[[User:LKolesar|LKolesar]] 08:33, 2012 April 17 (CDT)
*At the Vic, we will code a CAP on a COPD patient if the patient is on antibiotics AND a chest X-ray is showing infiltrates and indicates that a CAP is likely. Judy


==Also see==
== CCMDB Data Integrity Checks ==
*[[Pneumonia Etiology not clear]]  
A CAP is not allowed in acquired/complications. While in hospital a patient can acquire a [[VAP]] if ventilated or a [[HAP]] but not CAP. Rule added in version ver 2012-04-12.
*[[HAP]] Hospital acquired pneumonia
*[[VAP]] Ventilator acquired/associated pneumonia


This will no longer be relevant in ICD10 because of how it is coded there. Ttenbergen 17:51, 2018 April 4 (CDT)


[[Category: Diagnosis Coding]]
==See also==
[[Category: Infection]]
[[:Category: Pneumonia (old)| Pneumonia]]
[[Category: Pneumonia]]
 
[[Category:Infection (old)]]
[[Category:Pneumonia (old)]]

Latest revision as of 10:29, 30 July 2025



Legacy Content

This page is about the pre-ICD10 diagnosis coding schema. See the ICD10 Diagnosis List, or the following for similar diagnoses in ICD10:Pneumonia, bacterial, SARS (severe acute respiratory syndrome), Aspiration pneumonitis

Click Expand to show legacy content.


edit dx infobox
Category/Organ
System: 		Category: Infection (old)

Type:

Category: Medical Problem (old)

Main Diagnosis: Pneumonia
Sub Diagnosis: PNEUMONIA-CAP
Diagnosis Code: 3700 - CAP-Community Acquired Pneumonia
Comorbid Diagnosis: No
Charlson Comorbid coding (pre ICD10): 0
Program: CC & Med
Status: Currently Collected


  • CAP is coded if the pneumonia is evident within the first 48 hours of admission, this includes patients where the doctor is calling it a pneumonia and are treating it with antibiotics with or without a positive culture. If the doctor is calling it an aspiration pneumonia, this is a misnomer, it should be called aspiration pneumonitis. Pneumonia is an infectious process and while aspiration can pre-dispose someone to pneumonia, it should not be called pneumonia until there is clear evidence of such (organism isolated, CXR worsening infiltrates, antibiotics started, increased oxygen requirements, etc.) This is per Dr. Garland. --LKolesar 11:27, 2013 March 7 (EST)
  • In the setting of a known aspiration event:

Use Pneumonitis 2nd Chemical Aspiration (3019) instead of utilizing the aspiration subcode located in the pathogen section. (per Dr.Garland)

  • code CAP-with organism in the admit diagnosis section if a pathogen IS isolated from a culture drawn within 48 hour or less of admission. If this happens you can still leave the pneumonitis 2nd chemical aspiration if there is room for both.
  • Note a CAP can be coded with or without an aspiration. Also, pneumonitis 2nd aspiration can be coded without coding a pneumonia.

If pathogen IS isolated from a culture drawn greater than 48 hours AFTER admission, code as a HAP with organism which is coded in the complication section.

    • Note: a sterile aspiration can become superinfected while in hospital.

CCMDB Data Integrity Checks

A CAP is not allowed in acquired/complications. While in hospital a patient can acquire a VAP if ventilated or a HAP but not CAP. Rule added in version ver 2012-04-12.

This will no longer be relevant in ICD10 because of how it is coded there. Ttenbergen 17:51, 2018 April 4 (CDT)

See also

Pneumonia

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