CAP-Community Acquired Pneumonia
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 pneumonitisClick Expand to show legacy content.
| edit dx infobox | |
| Category/Organ System: |
Category: Infection (old) |
|
Type: |
|
| 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.
Template: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.