Present on Admission POA Indicator

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Present on Admission (POA) Indicator

• Barry Libman, RHIA, CCS, CCS-P
• President, Barry Libman Inc.

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Deficit Reduction Act (DRA)

• Section 5001. Hospital Quality Improvement By
  not later than October 1, 2007, the secretary
  shall select diagnosis codes associated with at
  least two conditions, each of which codes meets
  all of the following requirements (as determined
  by the Secretary)
• Cases described by such code have a high cost or
  high volume, or both under this title.
• The code results in the assignment of a case to a
  diagnosis-related group that has a higher payment
  when the code is present as a secondary
  diagnosis.
• The code describes such conditions that could
  reasonably have been prevented through the
  application of evidence based guidelines

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Present on Admission (POA) Indicator

• Methodology for data collection
• An indicator that captures whether or not a
  diagnosis was present at the time of inpatient
  admission.
• Applies to Inpatient Encounters
• Principal diagnosis code
• Secondary diagnosis code
• E-Codes

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Present on Admission (POA) Indicator

• UB 04 Mandate
• State of New York 1994
• State of California 1996
• State of Massachusetts 10/1/2006 (editing
  1/2007)
• Inpatient
• Observation
• Emergency Department

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POA Rationale

• Distinguish between co-morbidity (pre-existing
  conditions) and complications
• Increase efficiency of quality of care indicators
• Reduce of false positives that need further
  investigation
• Improve accuracy of safety and quality measures
• Mortality risk assessment
• Potentially Preventable Complications (PPC)
• Complications Screening Program (CSP)
• Risk adjustment methodologies
• Outcomes research
• Increase validity of hospital report card
• Pay for Performance Program fairness

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POA Rationale

• Timing is everything- When was the condition
  present?
• Patient has a diagnosis of pneumonia ..
• If not POA, then hospital acquired?
• Patient has a fracture of the hip..
• If not POA, then hospital acquired?
• Patient had surgery and has a fever..
• If not POA, then hospital acquired?

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POA Reporting Requirements

• Is the condition present at the time the order
  for inpatient admission occurs?
• Did the condition develop during an outpatient
  encounter including emergency department,
  observation and outpatient surgery prior to
  admission?
• Issues related to inconsistent, missing,
  conflicting, or unclear documentation must by
  resolved by the provider.

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POA indicators
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POA indicator Y

• Yes, the condition is POA if
• Explicitly documented by the provider as present
  on admission
• Conditions diagnosed prior to admission
• Conditions documented as suspected, possible,
  rule-out, differential DX, or constitute an
  underlying cause of a symptom that is POA but the
  DX is subsequently confirmed after admission

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POA indicator Y

• Any condition that develops during an outpatient
  encounter prior to a written order for inpatient
  admission
• Conditions documented as suspected, possible,
  rule out, at the time of discharge as well as at
  the time of admission
• Any condition diagnosed during the admission that
  were clearly present but not diagnosed until
  after the admission occurred
• If all the terms in the code description are
  present on admission

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POA indicator Y

• Any chronic condition, even if diagnosed after
  admission
• Comparative or contrasting dx, both present on
  admission
• Organism to an infection, present on admission
• Congenital conditions and anomalies
• Newborns, any condition present at birth or
  develops in utero

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POA indicator N

• No, the condition is not POA if
• Explicitly documented by the provider as not
  present on admission
• If any of the terms in the code description are
  not present on admission
• Conditions documented as suspected, possible,
  rule out, at the time of discharge but the
  symptoms or clinical findings were not present on
  admission

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POA indicator U

• Unknown whether condition is POA if
• When the medical records documentation is unclear
  as to whether the condition was present on
  admission
• Coders are encouraged to query the provider when
  the documentation is unclear

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POA indicator W

• Clinically undetermined whether condition is POA
  if
• When the medical record documentation indicates
  that it cannot be clinically determined whether
  or not the condition was present on admission

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POA indicator left blank

• Unreported or exempt conditions
• Leave the POA field blank if the condition is on
  the list of ICD-9-CM codes exempt from reporting

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Examples

• A patient is treated in Observation and while in
  Observation, the patient falls out of bed and
  breaks a hip. The patient is subsequently
  admitted as an inpatient to treat the hip
  fracture.
• Assign Y to POA field for the hip fracture
  since in developed prior to a written order for
  inpatient admission

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Examples

• A patient with known CHF is admitted to the
  hospital after he develops decompensated
  congestive heart failure.
• Assign Y to POA field for the congestive heart
  failure. The ICD-9-CM code identifies the chronic
  condition and does not specify the acute
  exacerbation.

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Examples

• A patient with viral hepatitis B progresses to
  hepatic coma after admission.
• Assign N to the viral hepatitis B with hepatic
  coma because part of the code description did not
  develop until after admission

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Examples

• 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 to POA field for the atrial
  fibrillation since it developed prior to a
  written order for inpatient admission.

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Examples

• A single liveborn infant delivered in the
  hospital via C-section. The doctor documented
  fetal bradycardia during labor in the final
  diagnosis in the newborn record.
• Assign Y to POA field because the bradycardia
  developed prior to the newborn admission (birth).

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Examples

• A newborn developed diarrhea which was believed
  to be due to the hospital baby formula.
• Assign N because the diarrhea developed after
  admission.

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Examples

• A patient admitted for repair of an abdominal
  aneurysm however the aneurysm ruptures after
  hospital admission prior to surgery.
• Assign N for the ruptured abdominal aneurysm.
  Although the aneurysm was present on admission,
  the ruptured component of the code description
  did not occur until after admission

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Examples

• A patient with a history of varicose veins and
  ulceration of the left lower extremity strikes
  the area against the side of his hospital bed
  during an inpatient hospitalization. It bleeds
  profusely. The final diagnosis list varicose
  veins with ulcer and hemorrhage.
• Assign Y for varicose vein with ulcer. Although
  the hemorrhage occurred after admission, the code
  description for varicose veins does not mention
  hemorrhage.

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Comments and QuestionsCoding Concerns

• Physician documentation important!
• HP, progress notes, clinical indications for
  tests, Emergency Department notes
• Final determination of POA?
• Additional queries
• Do we set up guidelines?
• How will the data be used? Some states not sure
  yet (thinking pay for performance Medicaid)
• Should we monitor?
• How do we monitor?
• Who should monitor? MRC, QM
• How do we educate the physicians?

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Resources

• The Case for the Present on Admission Indicator
  (HCUP)
• http//www.hcup-us.ahrq.gov/reports/2006_1.pdf
• National Center Health Statistics Guidelines
• http//www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icd
  guide07.pdf
• State of California- Office of Statewide Health
  Planning OSHPD
• http//www.oshpd.ca.gov/
• Deficit Reduction Act Section 5001 Hospital
  Quality Improvement http//thomas.loc.gov/cgi-bin
  /cpquery/?dbnamecp109sidcp109793l0referr_n
  hr362.109itemselTOC_78519
• Key Points of the UB-04 Journal of AHIMA October
  2006
• http//www.ahima.org/

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Questions?

• Barry Libman, RHIA, CCS, CCS-P
• President, Barry Libman Inc.
• 978-369-7180
• Barry_at_barrylibmaninc.com
• www.barrylibmaninc.com