CAP-Community Acquired Pneumonia

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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

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Category/Organ System:	Category: Infection (old)
Type:	[[:Category: Medical Problem (old)]][[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

Template:Data Integrity Rules

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.

Question

• 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.--LKolesar 08:33, 2012 April 17 (CDT)
  • 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?

Question

• 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-Trish Ostryzniuk 14:25, 2012 April 13 (CDT) & 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).--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.--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

• Pneumonia Etiology not clear
• HAP Hospital acquired pneumonia
• VAP Ventilator acquired/associated pneumonia