Assigning POA (Present on Admission)

Be Prepared To Assign POA Indicators.

Coders must understand POA indicators and the affect on Medicare reimbursement under IPPS.

Reporting related to reporting the Present on Admission (POA) indicator. This column will go into more detail on the reporting requirements for the POA indicator and will also discuss the Centers for Medicare and Medicaid Services (CMS) identified Hospital-acquired Conditions (HAC) and their codes that, if not present on admission, will not be considered in determining the MS-DRG assignment.

POA Indicator:

POA is defined as present at the time the order for inpatient admission occurs. The purpose of the POA indicator is to differentiate between conditions present at the time of admission from those conditions that develop during the inpatient admission. 

Going forward you cannot code a Medicare inpatient case without also assigning the POA indicator. Therefore, coders must become as proficient in the assignment of the POA indicator as they are in capturing complications and comorbidities (CCs) and major CCs (MCCs). 

Reporting Requirements.

The Deficit Reduction Act of 2005 (DRA) requires that CMS implement the reporting of the POA indicators for all diagnoses reported on Medicare claims for inpatient acute care discharges beginning Oct. 1, 2007. 

Critical access hospitals, Maryland waiver hospitals, long-term care hospitals, cancer hospitals and children's inpatient facilities are exempt from this requirement.

Hospitals that improperly submit the POA indicator for discharges on or after Jan. 1, 2008, will receive remittance advice remark code N36.3 informing them that they failed to report a valid POA indicator: "Alert: in the near future we are implementing new policies/procedures that would affect this determination." 

According to CMS when you see this remark code on your remittance advice, it is to alert you that there is a problem with your submission of POA.

Beginning with discharges on or after April 1, 2008, fiscal intermediaries will return claims to hospitals that do not include a valid POA indicator for each diagnosis on the claim. Hospitals will then have to supply the correct POA indicator and resubmit the claim.

POA Reporting Guidelines.

The POA indicator is required for the principal and all secondary diagnoses to determine whether a selected condition developed during a hospital stay. Specific instructions on how to select and report the correct POA indicator are included in the "ICD-9-CM Official Guidelines for Coding and Reporting" and in CMS Transmittal 1240.

The POA guidelines are to be used as a supplement to the ICD-9-CM Official Guidelines to facilitate the assignment of the POA indicator for each diagnosis and external cause of injury code reported on the UB-04 and 837 Institutional claim forms. CMS does not require a POA indicator for external cause of injury codes unless they are reported as an "other diagnosis."

Conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery, are considered as POA. Medical record documentation from any provider involved in the care and treatment of the patient may be used to determine whether a condition was POA or not. 

In this context, the term provider means a physician or any qualified health care practitioner who can legally establish the patient's diagnosis. 

A list of categories and codes exempt from POA reporting is provided in the guidelines. These codes are exempt because they represent circumstances that do not represent a current disease or injury or are always POA. 

Assigning the POA Indicator.

The POA indicator is reported using one of the following variables:

Y = Yes = present at the time of inpatient admission

N = No = not present at the time of inpatient admission

U = Unknown = the documentation is insufficient to determine if the condition was present at the time of inpatient admission

W = Clinically Undetermined = the provider is unable to clinically determine whether the condition was present at the time of inpatient admission or not

1 = Unreported/Not used - Exempt from POA reporting - This code is the equivalent code of a blank on the UB-04, however, it was determined that blanks were undesirable when submitting this data via the 4010A1. 

The "ICD-9-CM Official Guidelines for Coding and Reporting" instructs the use of a Blank for reporting the POA for exempt codes. However, Medicare does require that "1" be reported.

When to assign Y 

Assign Y for any condition the provider explicitly documents as being POA. Assign Y for conditions that were diagnosed prior to admission. 

For example: hypertension, diabetes mellitus, asthma. Assign Y for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred. Diagnoses subsequently confirmed after admission are considered POA if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis or constitute an underlying cause of a symptom present at admission. 

Assign Y for any condition that develops during an outpatient encounter prior to a written order for inpatient admission. For example, a patient undergoes outpatient surgery. During the recovery period, the patient develops atrial fibrillation and the patient is subsequently admitted to the hospital as an inpatient. Assign Y on the POA field for the atrial fibrillation because it developed prior to a written order for inpatient admission.

When to assign N 

Assign N for any condition the provider explicitly documents as not present at the time of admission. For example, a patient is admitted to the hospital for a coronary artery bypass surgery. Postoperatively he developed a pulmonary embolism. Assign N on the POA field for the pulmonary embolism. 

This is an acute condition that was not POA. If the final diagnosis contains a possible, probable, suspected, or rule out diagnosis, and this diagnosis was based on symptoms or clinical findings that were not POA, assign N.

When to assign U

Assign U when the medical record documentation is unclear as to whether the condition was POA. U should not be routinely assigned and should be used only in very limited circumstances. Coders are encouraged to query the providers when the documentation is unclear.

When to assign W

Assign W when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was POA. 

Combination Codes 

If the combination code only identifies the chronic condition and not the acute exacerbation assign Y. For example, acute exacrbation of CHF Assign N if any part of the combination code was not POA. 

For example, obstructive chronic bronchitis with acute exacerbation and the exacerbation was not POA; viral hepatitis B progresses to hepatic coma after admission Assign Y if all parts of the combination code were POA. For example, patient with diabetic nephropathy is admitted with uncontrolled diabetes.

Obstetric Conditions.

If the obstetrical code includes more than one diagnosis and any of the diagnoses identified by the code were not POA assign N. For example, pre-eclampsia or eclampsia superimposed on preexisting hypertension assigned with code 642.7X. If the pregnancy complication or obstetrical condition was not POA assign N. For example, patient admitted in active labor. 

After 12 hours of labor it is noted that the infant is in fetal distress and a Cesarean section is performed. Assign N for the fetal distress.

Perinatal conditions

Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered POA and should be assigned Y. 

This includes conditions that occur during delivery. For example, injury during delivery and meconium aspiration.

Congenital conditions and anomalies

Assign Y for congenital conditions and anomalies. Congenital conditions are always considered POA. For example, congenital hydrocephalus.

Codes exempt from reporting

Codes exempt from reporting are listed in the coding guidelines and are reported with the POA indicator of 1. These codes are exempt because the codes do not represent a current disease or injury or are always POA. 

For example, old MI, late effects of cerebrovascular disease and normal delivery.