Reinforce Documentation to Identify POA Indicators
To assign an appropriate diagnosis related group (DRG), you must correctly identify present on admission (POA) indicators on all inpatient claims for services rendered in general acute care hospitals. This may be challenging if there are documentation deficiencies in the medical record. Here’s how to remedy those deficiencies.
POA is defined as conditions present at the time the order for an inpatient admission is executed. This includes conditions developing during an outpatient encounter, including in the emergency department (ED), observation, or ambulatory surgery.
Each coded diagnosis requires a POA indicator. The ICD-10-CM Official Guidelines for Coding and Reporting advises, “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnosis and procedures.”
Best practice: Query the provider when the documentation is not clear enough to assign the POA indicator properly.
Know Your Options
There are four reporting options (with some conditions exempt from reporting):
- Y (Yes: Present at the time of the inpatient admission)
- N (No: Not present at the time of the inpatient admission)
- U (Unknown: The documentation is insufficient to determine if the condition is POA)
- W (Clinically undetermined: The provider is unable to determine whether the condition was POA)
The Centers for Medicare & Medicaid Services (CMS) tells us not to assign U routinely, but to use it in limited circumstances.
Best practice: Check with your facility for possible internal guidelines for reporting U and W.
Look for Indicators in the Medical Record
Examples of when to assign Y (POA):
a. Any condition the provider unquestionably documents as POA
b. Conditions diagnosed prior to the admission (e.g., chronic conditions)
c. Conditions diagnosed during the admission that were clearly POA, but diagnosed post admission (e.g., admitted with melena, nausea/vomiting, and intractable abdominal pain, final diagnosis is stomach cancer)
d. A condition that develops during an outpatient encounter prior to a written order for inpatient admission
e. A newborn condition present at birth, developing in utero, or occurring during delivery (e.g., meconium aspiration)
f. A condition documented as possible, probable, suspected, or rule-out at the time of discharge, which was suspected upon admission
g. Scenarios where a single code identifies the chronic condition only and not the acute exacerbation (e.g., acute exacerbation of chronic leukemia)
Examples of when to assign N (not POA):
a. A condition the provider unquestionably documents as not being POA
b. The final diagnosis contains possible, probable, suspected, or rule-out at the time of discharge, but was not suspected on admission
c. The final diagnosis contains an impending/threatened diagnosis, but was not suspected on admission
d. Scenarios where a combination code is assigned and any part of the code was not POA (e.g., acute exacerbation of COPD, in which the exacerbation occurring post admission)
e. A pregnancy/obstetrical complication not POA (e.g., laceration during delivery)
ICD-10-CM Official Guidelines for Coding and Reporting
CMS, Hospital-Acquired Conditions (Present on Admission Indicator), Coding:
Lee Williams, RHIT, CPCO, CPC, CEMC, CCS, CCDS, has more than 14 years of experience as a coding director, auditor, educator, trainer, and practice manager. She holds a degree in Health Information Technology and is director of Medical Coding at Ga Cancer Specialists/Northside Hospital Cancer Institute. Williams also provides consulting services for Karna, LLC, on research coding projects sponsored by the Centers for Disease Control and Prevention and U.S. Consumer Product and Safety Commission. Her specialties include medical coding, E/M auditing, ED coding/auditing, DRG assignment, CDI, CMS guidelines, OIG restructuring, MAC/RAC/ZPIC audits, HIPAA, physician/coder training, and pay for performance measures. She serves on AAPC’s National Advisory Board, representing Region 4.
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