July 24, 2019

Inpatient Coding: Defining ‘Present on Admission’

In today’s rapidly developing pay-for-performance healthcare environment, collection, quality, and interpretation of present on admission (POA) indicators continues to play a key role in the inpatient coder’s responsibilities.

What is POA?

POA is defined as a condition that is present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered to be POA.

Coding options

Providers must report one of five indicators:

  • Y = yes (present at the time of inpatient admission)
  • N = no (not present at the time of inpatient admission)
  • U = unknown (documentation is insufficient to determine if condition was present at the time of admission)
  • W = clinically undetermined (provider is unable to clinically determine whether condition was present on admission)
  • 1 (on electronic claims) or blank (for paper claims) = exempt from POA reporting

The importance of documentation

Ideally, a physician works with hospital staff and coders to determine the best way to communicate POA information. POA indicators are assigned to principal and secondary diagnoses and external cause injury codes.  One recommendation is for physicians to simply put ‘POA’ in their notes next to their diagnosis. The Centers for Medicare and Medicaid Services (CMS) has suggested that the discharging physician clearly indicate in the discharge summary which of the conditions were or were not present on admission.

The Deficit Reduction Act of 2005 mandated that providers report POA indicators for all diagnoses submitted on Medicare inpatient acute care claims for discharges beginning October 1, 2007.  One year later, CMS announced that it intended to stop paying the costs of treating what it deemed to be preventable inpatient complications (Medicare No-Pay List).  This was a controversial move since the responsibility then fell to physicians and hospitals, not up to Medicare, to resolve documentation that is inconsistent, missing, conflicting, or unclear.

Like other coded data, the POA indicator is increasingly used for multiple purposes – reimbursement, clinical research, financial planning and quality of care evaluation. Successfully implementing POA reporting requires educating physicians and hospital staff on their roles in correct POA assignment.

If the coder encounters POA documentation that is unclear, they must query the provider. The physician is responsible for resolving the insufficiency.

Cynthia Alder-Smith, RHIT CCS

Auditor/ Educator Excite Health Partners