|Pre-ICD10 counterpart:||CAP-Community Acquired Pneumonia, HAP-Hospital Acquired Pneumonia, VAP - Ventilator Associated Pneumonia|
|APACHE Como Component:||none|
|APACHE Acute Component:||2019-0: Respiratory Infection|
|External ICD10 Documentation|
This diagnosis is a part of ICD10 collection.
- Mainly, this code is used when it's believed an infectious pneumonia is present, but if the type of organism is not known (i.e. it can not be coded more specifically).
VAP supersedes this code
- The diagnosis of VAP Pneumonia, ventilator-associated (VAP) supercedes this code.
HAP vs CAP
- For coding of hospital-acquired Pneumonia, NOS, see Hospital-acquired pneumonia (HAP) in ICD10
- To decide about whether a CAP or HAP has occurred, requires clinical correlation.
- For example, sputum is almost never sterile -- bugs will always grow from it. It's even true that bronchoscopic lower respiratory samples are almost never sterile, which is why quantitative culture is used to interpret them. THUS, respiratory fluid that grows bugs cannot by itself be used to interpret the presence of pneumonia EXCEPT in the rare cases of bugs that are never pathogens in the respiratory system -- that list is mainly limited to: TB, Legionella, and Pneumocystis jiroveci. Thus, a (+) sputum culture can almost never by itself be used to identify the presence of a pneumonia. Instead, it's a combination of clinical signs such as fever, leukocytosis and new (or presumed new) CXR changes that helps to figure it out. Indeed, one can diagnose CAP or VAP in the absence of a (+)sputum culture in the right situation (e.g. patient has been on antibiotics for some reason prior).
In the context of COVID
Some special rules apply in the context of COVID infections, see COVID-19 (SARS-COV-2)#Coding of pneumonia in the context of COVID.
Alternate ICD10s to consider coding instead or in addition
Candidate Combined ICD10 codes
- Add Iatrogenic, complication of medical or surgical care NOS to make viral hospital-acquired pneumonia
Infections in ICD10 have combined coding requirements for some of their pathogens. Any that have antibiotic resistances would store those as Combined ICD10 codes as well. If the infection is acquired in the hospital, see Nosocomial infection, NOS. See Lab and culture reports for confirmation and details about tests. See Infections in ICD10 for more general info.
Attribution of infections
Related CCI Codes
Data Integrity Checks (automatic list)
|Query check ICD10 Inf Infection req Pathogen must have one||CCMDB.accdb||implemented|
|Query Check Inf Pathogens must have Infection requiring pathogen or Potential Infection||CCMDB.accdb||implemented|