IMPORTANT TOPICS TO REVIEW FOR CCS PREPRATION
ICD-9-CM Diagnoses:
· Heart valve disease, with/without heart disease
· Combination codes for hypertension with heart or renal failure
· Congenital disorders treated later in life
· Late effect codes (how late is late?)
· Any section of the official guidelines that has multiple instructions (neoplasms, cardiovascular, HIV, etc.)
· Fifth digit designations (DM, osteoarthritis)
· Complications (confirming causative relationship, correct sequencing)
· Identifying infectious organisms
· Complicated wounds, crush injuries
· Differentiating primary from secondary neoplasms
· Symptoms (when it is appropriate to report them separately, inpt vs outpt use)
· Specified vs unspecified anemias
· Mental disorders (lots of changes for 2005)
· CAD if native vs. bypass vessel
· Atherosclerosis category 440.2x (explain includes notes)
· Cholecystitis (acute, chronic, with/without stones)
· OB delivery with problems (multiple codes, causes of obstructed labor)
ICD-9-CM Vol III Procedures:
· Endoscopic procedures (are there any places left where this approach is not specifically delineated?)
· Omit operative approach (laminectomy)
· Biopsy vs. excision of lesion
· PTCA (what’s included- thrombolytic, what’s not- drug eluting stent)
· Heart caths (multiple coding)
· Intestinal procedures (excisions, with/without anastomosis)
· Fracture repairs with bone grafts
· Spinal fusion (multiple coding)
CPT:
· Excision of lesions
· Skin grafts
· Breast procedures
· Bunionectomy
· Hammertoe procedures
· Bronchoscopy
· Nasal/sinus endoscopy
· Arteriovenous fistulas
· Central venous access
· Laminectomies
· Strabismus surgery
· Spinal fusion
· New procedures for control of epilepsy
· CABG
· Hemodialysis access
· Nissen fundoplasty
· Incomplete colonoscopy
· Transurethral procedures
· Repair of genital prolapse
· Scleral buckle or other type of scleral procedure instead of cataracts
Tuesday, April 12, 2011
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.
Why is POA 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/.
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.
Why is POA 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/.
Coding clinics on POA indicator
AHA Coding Clinicâ for ICD-9-CM, 3Q 2008, Volume 25, Number 3, Page 20
Notice
Section 5001(c) of Pub. L. 109-71 requires the Secretary of the Department of Health and Human Services to identify a list of hospital-acquired conditions and to collect information regarding such conditions. The Department of Health and Human Services' Centers for Medicare & Medicaid Services (CMS) has developed a process for hospitals to submit a Present on Admission (POA) indicator with each diagnosis. For more specific instructions on Medicare POA indicator reporting instructions, refer to
http://www.cms.hhs.gov/HospitalAcqCond/02_Statute_Regulations_Program_Instructions.asp#TopOfPage
The American Hospital Association (AHA) and the Centers for Medicare & Medicaid Services (CMS) are collaborating on the design of a mechanism to receive, analyze and respond to questions about POA coding. In the interim, the Cooperating Parties for ICD-9-CM have developed responses to the most frequently asked POA indicator reporting questions.
AHA Coding Clinicâ for ICD-9-CM, 1Q 2009, Volume 26, Number 1, Page 19
Frequently Asked POA Questions
Clarification: Stage II Pressure Progressing to Stage III
Question: Coding Clinic Fourth Quarter 2008, page 194 stated that a stage II pressure ulcer, which was present on admission, and progresses to become a stage III pressure ulcer during the stay is reported as “Yes” for the present on admission (POA) indicator. However, the POA indicator is reported for conditions present at the time of inpatient admission. It appears inconsistent to report a Stage III pressure ulcer as present on admission since the pressure ulcer gradually deteriorated during the hospital stay. Could Coding Clinic please clarify this issue for coders and clinical teams that rely on this guidance?
Answer: In terms of coding and POA reporting, a pressure ulcer is only coded and reported once at the highest stage. The information published in Coding Clinic Fourth Quarter 2008, page 194, instructing to report a Stage II pressure ulcer that progresses to a Stage III as present on admission is correct. The pressure ulcer was present on admission; therefore, the POA should be yes. This advice is consistent with the National Quality Forum (NQF) endorsed measures. The NQF established a standardized set of serious reportable events also called never events. The list of serious reportable events excludes the progression of a pressure ulcer from stage II to Stage III, if stage II was recognized upon admission.
The NQF is an organization created to develop and implement a national strategy for health care quality measurement and reporting. Please refer to the NQF website for additional information about “Serious Reportable Events in Healthcare”:
AHA Coding Clinicâ for ICD-9-CM, 3Q 2008, Volume 25, Number 3, Page 20-21
Frequently Asked POA Questions
Question: We have heard that the documentation of a pressure ulcer has to be completed within two calendar days of admission. Also, we often query the physician post discharge if the coder cannot make the determination of POA with the documentation in the record. Will this process still be allowed in FY 2009?
Answer: There is no required timeframe as to when a provider (per the definition of “provider” used in the Official Guidelines for Coding and Reporting) must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. If at the time of code assignment, the documentation is unclear as to when a condition developed, it is appropriate to query the physician for clarification.
http://www.qualityforum.org/pdf/reports/sre/txsrepublic.pdf
AHA Coding Clinicâ forICD-9-CM, 4Q 2008, Volume 25, Number 4, Page 194
Frequently Asked POA Questions
Question: A patient is admitted to the hospital with a stage II pressure ulcer of the heel. During the hospitalization, the pressure ulcer worsens and becomes a stage III. Based on the new Official Coding Guidelines, we would be assigning the code for the highest stage for that site. What would be the correct POA indicator assignment for the stage III code?
Answer: Assign “Y” to the pressure ulcer stage III code since this code is referring to a pressure ulcer that was present on admission rather than a new ulcer.
AHA Coding Clinicâ for ICD-9-CM, 1Q 2010,Volume 27, Number 1, Pages 18-19
Frequently Asked POA Questions
Question: A 70-year-old female with chronic obstructive pulmonary disease (COPD) was admitted with an acute exacerbation of COPD. The patient presented to the hospital with acute respiratory distress and hypoxia. On day two, she was transferred to the intensive care unit (ICU) and placed on mechanical ventilation to treat acute respiratory failure. The patient's respiratory issues were stabilized and the patient was discharged home. What are the appropriate POA indicators?
Answer: For coding and reporting purposes, both the COPD exacerbation and the acute respiratory failure would be separately coded.
The POA indicator for the acute exacerbation of the COPD is “Y.” If the health record documentation is not clear regarding whether respiratory failure was present on admission, query the provider for clarification. If the provider responds that the respiratory failure developed after admission, assign a POA indicator of “N.” If the provider cannot determine whether the respiratory failure was present on admission, assign a POA indicator of “W.”
Question: The patient, a 76-year-old male, presented to the emergency department (ED) with a three-day onset of respiratory distress. In the ED, the patient rapidly deteriorated, developing acute respiratory failure which led to his admission. He was admitted to the intensive care unit of the hospital and placed on mechanical ventilation. The patient was discharged following an uneventful hospital course. What are the POA indicators for this case?
Answer: The principal diagnosis would be acute respiratory failure since this was the reason the patient was admitted to the hospital. A separate code for respiratory distress would not be reported.
The POA indicator for the acute respiratory failure is “Y” since the acute respiratory failure developed prior to admission.
AHA Coding Clinicâ for ICD-9-CM, 3Q 2008, Volume 25, Number 3, Page 21
Frequently Asked POA Questions
Question: Do we need to assign a POA indicator to E-codes?
Answer: While many E codes are exempt from POA reporting (refer to the list of exempt codes on the Official Guidelines for Coding and Reporting) and will be reported with an “1” for Medicare, many other E codes will require reporting of the POA indicator if they are reported among the secondary diagnoses. Examples of the code ranges requiring POA reporting are Accidental poisonings by drugs, medical substances and biologicals (E850-E858), and Drugs, medicinal and biological substances causing adverse effects in therapeutic use (E930-E949), among others.
AHA Coding Clinicâ for ICD-9-CM, 2Q 2010, Volume 27, Number 2, Page 14
Frequently Asked POA Questions
Question: A patient is admitted with a subarachnoid hemorrhage following an injury. At the time of admission there was no mention of loss of consciousness. However, after admission the patient lost consciousness for several hours. We assigned code 852.03, subarachnoid hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness, as the principal diagnosis. What is the appropriate POA indicator since the patient lost consciousness after admission?
Answer: Assign POA indicator “Y” since the injury occurred prior to admission. Loss of consciousness is part of the natural history of the disease process. In addition, the POA guideline governing combination codes does not apply here, since this is not a combination of diagnoses. The skull fracture (800-804) and intracranial injury (850-854) categories are unique, so this advice only applies to these categories.
Notice
Section 5001(c) of Pub. L. 109-71 requires the Secretary of the Department of Health and Human Services to identify a list of hospital-acquired conditions and to collect information regarding such conditions. The Department of Health and Human Services' Centers for Medicare & Medicaid Services (CMS) has developed a process for hospitals to submit a Present on Admission (POA) indicator with each diagnosis. For more specific instructions on Medicare POA indicator reporting instructions, refer to
http://www.cms.hhs.gov/HospitalAcqCond/02_Statute_Regulations_Program_Instructions.asp#TopOfPage
The American Hospital Association (AHA) and the Centers for Medicare & Medicaid Services (CMS) are collaborating on the design of a mechanism to receive, analyze and respond to questions about POA coding. In the interim, the Cooperating Parties for ICD-9-CM have developed responses to the most frequently asked POA indicator reporting questions.
AHA Coding Clinicâ for ICD-9-CM, 1Q 2009, Volume 26, Number 1, Page 19
Frequently Asked POA Questions
Clarification: Stage II Pressure Progressing to Stage III
Question: Coding Clinic Fourth Quarter 2008, page 194 stated that a stage II pressure ulcer, which was present on admission, and progresses to become a stage III pressure ulcer during the stay is reported as “Yes” for the present on admission (POA) indicator. However, the POA indicator is reported for conditions present at the time of inpatient admission. It appears inconsistent to report a Stage III pressure ulcer as present on admission since the pressure ulcer gradually deteriorated during the hospital stay. Could Coding Clinic please clarify this issue for coders and clinical teams that rely on this guidance?
Answer: In terms of coding and POA reporting, a pressure ulcer is only coded and reported once at the highest stage. The information published in Coding Clinic Fourth Quarter 2008, page 194, instructing to report a Stage II pressure ulcer that progresses to a Stage III as present on admission is correct. The pressure ulcer was present on admission; therefore, the POA should be yes. This advice is consistent with the National Quality Forum (NQF) endorsed measures. The NQF established a standardized set of serious reportable events also called never events. The list of serious reportable events excludes the progression of a pressure ulcer from stage II to Stage III, if stage II was recognized upon admission.
The NQF is an organization created to develop and implement a national strategy for health care quality measurement and reporting. Please refer to the NQF website for additional information about “Serious Reportable Events in Healthcare”:
AHA Coding Clinicâ for ICD-9-CM, 3Q 2008, Volume 25, Number 3, Page 20-21
Frequently Asked POA Questions
Question: We have heard that the documentation of a pressure ulcer has to be completed within two calendar days of admission. Also, we often query the physician post discharge if the coder cannot make the determination of POA with the documentation in the record. Will this process still be allowed in FY 2009?
Answer: There is no required timeframe as to when a provider (per the definition of “provider” used in the Official Guidelines for Coding and Reporting) must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. If at the time of code assignment, the documentation is unclear as to when a condition developed, it is appropriate to query the physician for clarification.
http://www.qualityforum.org/pdf/reports/sre/txsrepublic.pdf
AHA Coding Clinicâ forICD-9-CM, 4Q 2008, Volume 25, Number 4, Page 194
Frequently Asked POA Questions
Question: A patient is admitted to the hospital with a stage II pressure ulcer of the heel. During the hospitalization, the pressure ulcer worsens and becomes a stage III. Based on the new Official Coding Guidelines, we would be assigning the code for the highest stage for that site. What would be the correct POA indicator assignment for the stage III code?
Answer: Assign “Y” to the pressure ulcer stage III code since this code is referring to a pressure ulcer that was present on admission rather than a new ulcer.
AHA Coding Clinicâ for ICD-9-CM, 1Q 2010,Volume 27, Number 1, Pages 18-19
Frequently Asked POA Questions
Question: A 70-year-old female with chronic obstructive pulmonary disease (COPD) was admitted with an acute exacerbation of COPD. The patient presented to the hospital with acute respiratory distress and hypoxia. On day two, she was transferred to the intensive care unit (ICU) and placed on mechanical ventilation to treat acute respiratory failure. The patient's respiratory issues were stabilized and the patient was discharged home. What are the appropriate POA indicators?
Answer: For coding and reporting purposes, both the COPD exacerbation and the acute respiratory failure would be separately coded.
The POA indicator for the acute exacerbation of the COPD is “Y.” If the health record documentation is not clear regarding whether respiratory failure was present on admission, query the provider for clarification. If the provider responds that the respiratory failure developed after admission, assign a POA indicator of “N.” If the provider cannot determine whether the respiratory failure was present on admission, assign a POA indicator of “W.”
Question: The patient, a 76-year-old male, presented to the emergency department (ED) with a three-day onset of respiratory distress. In the ED, the patient rapidly deteriorated, developing acute respiratory failure which led to his admission. He was admitted to the intensive care unit of the hospital and placed on mechanical ventilation. The patient was discharged following an uneventful hospital course. What are the POA indicators for this case?
Answer: The principal diagnosis would be acute respiratory failure since this was the reason the patient was admitted to the hospital. A separate code for respiratory distress would not be reported.
The POA indicator for the acute respiratory failure is “Y” since the acute respiratory failure developed prior to admission.
AHA Coding Clinicâ for ICD-9-CM, 3Q 2008, Volume 25, Number 3, Page 21
Frequently Asked POA Questions
Question: Do we need to assign a POA indicator to E-codes?
Answer: While many E codes are exempt from POA reporting (refer to the list of exempt codes on the Official Guidelines for Coding and Reporting) and will be reported with an “1” for Medicare, many other E codes will require reporting of the POA indicator if they are reported among the secondary diagnoses. Examples of the code ranges requiring POA reporting are Accidental poisonings by drugs, medical substances and biologicals (E850-E858), and Drugs, medicinal and biological substances causing adverse effects in therapeutic use (E930-E949), among others.
AHA Coding Clinicâ for ICD-9-CM, 2Q 2010, Volume 27, Number 2, Page 14
Frequently Asked POA Questions
Question: A patient is admitted with a subarachnoid hemorrhage following an injury. At the time of admission there was no mention of loss of consciousness. However, after admission the patient lost consciousness for several hours. We assigned code 852.03, subarachnoid hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness, as the principal diagnosis. What is the appropriate POA indicator since the patient lost consciousness after admission?
Answer: Assign POA indicator “Y” since the injury occurred prior to admission. Loss of consciousness is part of the natural history of the disease process. In addition, the POA guideline governing combination codes does not apply here, since this is not a combination of diagnoses. The skull fracture (800-804) and intracranial injury (850-854) categories are unique, so this advice only applies to these categories.
Medicare Services
Medicare police given to:
A. with People age 65 or older,
B. People under age 65 certain disabilities, and
C. People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Medicare has:
Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.
Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.
Two types:
1. Medicare part A.
2. Medicare part B.
Medicare part A: Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Certain conditions must be met to get these benefits.
Cost: Most people don’t have to pay a monthly payment, called a premium, for Part A. This is because they or a spouse paid Medicare taxes while working. If a beneficiary doesn't get premium-free Part A, they may be able to buy it if they (or their spouse) aren’t entitled to Social Security, because they didn’t work or didn’t pay enough Medicare taxes while
working, are age 65 or older, or are disabled but no longer get free Part A because they returned to work.
If they have limited income and resources, their state may help them pay for Part A.
Medicare part B: Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Cost: The Medicare Part B premium each month ($78.20 per month in 2005). In some cases, this amount may be higher if the beneficiary didn’t sign up for Part B when they first became eligible.
Caution: If the beneficiary didn’t take Part B when they were first eligible, the cost of Part B will go up 10% for each full 12-month period that they could have had Part B but didn’t sign up for it, except in special cases. They will have to pay this penalty as long as they have Part B.
They also pay a Part B deductible each year before Medicare starts to pay its share. The Part B deductible for 2005 is $110.00. The beneficiary may be able to get help from their state to pay this premium and deductible.
Medicare deductible and premium rates may change every year in January.
A. with People age 65 or older,
B. People under age 65 certain disabilities, and
C. People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Medicare has:
Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.
Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.
Two types:
1. Medicare part A.
2. Medicare part B.
Medicare part A: Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Certain conditions must be met to get these benefits.
Cost: Most people don’t have to pay a monthly payment, called a premium, for Part A. This is because they or a spouse paid Medicare taxes while working. If a beneficiary doesn't get premium-free Part A, they may be able to buy it if they (or their spouse) aren’t entitled to Social Security, because they didn’t work or didn’t pay enough Medicare taxes while
working, are age 65 or older, or are disabled but no longer get free Part A because they returned to work.
If they have limited income and resources, their state may help them pay for Part A.
Medicare part B: Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Cost: The Medicare Part B premium each month ($78.20 per month in 2005). In some cases, this amount may be higher if the beneficiary didn’t sign up for Part B when they first became eligible.
Caution: If the beneficiary didn’t take Part B when they were first eligible, the cost of Part B will go up 10% for each full 12-month period that they could have had Part B but didn’t sign up for it, except in special cases. They will have to pay this penalty as long as they have Part B.
They also pay a Part B deductible each year before Medicare starts to pay its share. The Part B deductible for 2005 is $110.00. The beneficiary may be able to get help from their state to pay this premium and deductible.
Medicare deductible and premium rates may change every year in January.
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