Why is POA (Present on Admission) Important?

POA is an important because it helps differentiate between comorbidities and hospital-acquired complications. It is also important because CMS has determined that for some hospital-acquired conditions reimbursement may be affected.

Hospital-acquired Conditions

Why is Congress requiring hospitals to go to all the trouble of reporting the POA indicator? The DRA also includes a requirement that by Oct. 1, 2007, Medicare choose at least two conditions that are: High cost, high volume or both Assigned to a higher paying MS-DRG when present as a secondary diagnosis Reasonably preventable through application of evidence-based guidelines.

Beginning Oct. 1, 2008, codes representing these conditions will not be considered when calculating the MS-DRG assignment unless they were POA. In many cases, omission of these codes would result in a MS-DRG with a lower payment weight being assigned to the case. 

As a result, some hospital-acquired conditions could end up costing facilities much more. The POA condition, resulting in lower reimbursement, only applies when the selected conditions are the only CCs or MCCs present on the claim. If any other CC or MCC, not subject to the hospital-acquired infection provision, is present on the claim, the case will continue to be assigned to the higher-paying CC or MCC MS-DRG, and the MS-DRG assignment will not be affected.

CMS partnered with the Centers for Disease Control and Prevention (CDC) to identify potential high-volume, hospital-acquired conditions that hospitals could have reasonably prevented. Beginning on Oct. 1, 2008, cases with the following conditions will not be paid at a higher rate unless the conditions were POA.

1. Serious Preventable Event - Object Left in Surgery: CMS identifies "objects left in during surgery" as a serious preventable event. This means that this event should never occur during the health care encounter. This event is identified by diagnosis code 998.4, Foreign body accidentally left during a procedure.

2. Serious Preventable Event - Air Embolism: Air embolisms are also identified as a serious preventable event. This event is reported with diagnosis code 999.1, Complications of medical care, NOS, air embolism.

3. Serious Preventable Event - Blood Incompatibility: Although this event is rare, associated charges per case are high. There are prevention guidelines for avoiding the delivery of incompatible blood or blood products and this event should never occur. Blood incompatibility is identified by diagnosis code 999.6, Complications of medical care, NOS ABO incompatibility reaction.

4. Catheter-Associated Urinary Tract Infections (UTI): Catheter-associated UTIs are the most common hospital-acquired infection, accounting for more than 1 million cases in hospitals and nursing homes nationwide. 

It is estimated that hospital-acquired UTIs require one extra hospital day per patient at an estimated annual cost of $424 million to $451 million. These conditions are reported with code 996.64 Infection and inflammatory reaction due to indwelling urinary catheter and one of the following UTI codes; 112.2, 590.10, 590.11, 590.2, 590.3, 590.80, 590.81, 590.9, 595.0, 595.3, 595.4, 595.81, 595.89, 595.9, 597.0, 597.80, 599.0.

5. Pressure Ulcers: Pressure ulcers, also known as decubitus ulcers, are both a high cost and high volume condition, with more than 322,946 reported cases in FY 2006 with an average hospital charge of $40,381. CMS believes that selection of this condition will result in a closer examination of the patient's skin on admission, resulting in better quality of care. This diagnosis is identified by diagnosis codes 707.00 through 707.09

6. Vascular Catheter-Associated Infection: This condition appears to be both high cost and high volume, and there are prevention guidelines available. A new code was created effective Oct.1, 2007, to report this condition, 999.31, Infection due to central venous catheter. 

7. Surgical Site Infection-Mediastinitis after Coronary Artery Bypass Graft (CABG) Surgery: In its analysis of FY 2006 discharges, CMS identified 108 cases with a secondary diagnosis of mediastinitis in patients who had CABG surgery. These patients had average hospital charges of more than $300,000. This condition is identified in cases where there is both diagnosis code 519.2, Mediastinitis, and one or more of the CABG procedures codes 36.10 through 36.19 on the same claim.

8. Hospital-Acquired Injuries-Fractures, Dislocations, Intracranial Injury, Crushing Injury, Burn and Other Unspecified Effects of External Causes: CMS has not yet determined the codes that will be used to identify these conditons. They will be included in the FY 2009 proposed IPPS rule for comment. 

Conditions being considered for FY2009CMS also indicated that they are evaluating the following conditions. They may be included in the FY 2009 proposed IPPS rule for comment

1. Ventilator Associated Pneumonia (VAP)

2. Staphylococcus Aureus Septicemia

3. Deep Vein Thrombosis (DVT)/ Pulmonary Embolism (PE).

This article only discussed the Medicare requirements for POA and hospital-acquired conditions. There are some state specific requirements regarding the reporting of the POA indicator. To ensure compliance with any state-specific POA reporting requirement it is important to check with the appropriate state hospital association.

Take some time now to review in detail the FY 2008 ICD-9-CM Official Guidelines for Coding and Reporting related to POA at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf . 

You may also want to review the CMS Web site on Hospital-acquired Conditions at www.cms.hhs.gov/HospitalAcqCond/.