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.