CAP-Community Acquired Pneumonia: Difference between revisions

From CCMDB Wiki
Jump to navigation Jump to search
← Older editNewer edit →
TOstryzniuk (talk | contribs)
CCMDB_legit, approved, Bureaucrats, Administrators
27,522 edits
TOstryzniuk (talk | contribs)
CCMDB_legit, approved, Bureaucrats, Administrators
27,522 edits
mNo edit summary
TOstryzniuk (talk | contribs)
CCMDB_legit, approved, Bureaucrats, Administrators
27,522 edits
No edit summary
Line 1: Line 1:
{{DX tag | Infection | [[:Category: Medical Problem | Medical Problem]] | [[:Category: Pneumonia | Pneumonia]] | PNEUMONIA-CAP | [[3700 - CAP-Community Acquired Pneumonia]] | No | 0 |CC & Med |  Currently Collected | | |}}
{{DX tag | Infection | [[:Category: Medical Problem | Medical Problem]] | [[:Category: Pneumonia | Pneumonia]] | PNEUMONIA-CAP | [[3700 - CAP-Community Acquired Pneumonia]] | No | 0 |CC & Med |  Currently Collected | | |}}
*Admit DX: CAP-Aspiration 
**if clear aspiration AND no pathogen was isolated from a culture drawn within 48 hrs of admission or less. (culture will usually say normal flora or no organism)
*Admit DX CHANGE TO: CAP-with organism: 
**if a pathogen IS isolated from a culture drawn within 48 hrs of admission or less. 
If pathogen IS isolated from a culture drawn greater than 48 hrs AFTER admission, code as a [[HAP]] with organism. 
*[[User:TOstryzniuk|Trish Ostryzniuk]] 16:35, 2012 May 15 (CDT) as per Dr. Kumar reply on this date.


=={{Data Integrity Rules}}==
=={{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.  
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.
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.--[[User:LKolesar|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? - this is correct.[[User:TOstryzniuk|Trish Ostryzniuk]] 16:28, 2012 May 15 (CDT)
**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==
==Question==

Revision as of 16:35, 15 May 2012

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:Aspiration pneumonitis, Pneumonia, bacterial, SARS (severe acute respiratory syndrome)

Click Expand to show legacy content.


edit dx infobox
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


  • Admit DX: CAP-Aspiration
    • if clear aspiration AND no pathogen was isolated from a culture drawn within 48 hrs of admission or less. (culture will usually say normal flora or no organism)
  • Admit DX CHANGE TO: CAP-with organism:
    • if a pathogen IS isolated from a culture drawn within 48 hrs of admission or less.

If pathogen IS isolated from a culture drawn greater than 48 hrs AFTER admission, code as a HAP with organism.

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

Template:Discussion

  • 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

Retrieved from "https://ccmdb.kuality.ca/index.php?title=CAP-Community_Acquired_Pneumonia&oldid=26780"