tci Outpatient Facility Coding Alert - 2013 Issue 2

Reader Question: CAP Diagnosis Should Be 486

Question: The discharge diagnosis is "CAP bilateral." What does this mean? I’m not sure where to begin searching for this.South Carolina Subscriber Answer: CAP is an acronym for Community Acquired Pneumonia. If there’s additional information in the record, that would affect code choice. If this is the only information you have, report the diagnosis as 486 (Pneumonia organism unspecified). ...

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