One of the roles of a medical coder is to take information from the patient health record and report the correct codes to document patient diagnoses and procedures. One example of this is that medical coders must correctly assign present on admission (POA) indicators.
What Does POA Mean?
POA is a way for the hospital to determine which conditions existed before the patient came to the hospital and which conditions existed after admittance. Correct POA identification and use of POA indicators are important: they directly affect how insurance providers, Medicare, and patients are billed.
POA in medical coding includes any condition that develops during any outpatient encounter. This can include the emergency department, observation, and outpatient surgery.
For example, if you were admitted to the hospital with a strong cough and were having difficulty breathing, and if you were diagnosed with pneumonia, the pneumonia would be considered a condition that was present on admission. However, if you had no difficulties breathing at first and only started coughing after you were admitted, your cough would not be considered present on admission.
What Is a POA Indicator?
A POA indicator is the data element, shown as a single letter, that a medical coder assigns based on whether a diagnosis was present when the patient was admitted or not. .
A Present On Admission (POA) indicator is required on all diagnosis codes for the inpatient setting except for admission. The indicator should be reported for principal diagnosis codes, secondary diagnosis codes, Z-codes, and External cause injury codes.
What Are the Different POA Indicators?
Coders must use one of five different POA indicators when they are billing for POA conditions:
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 is present on admission and you cannot speak to the physician to figure it out
W–Clinically undetermined, provider is unable to clinically determine whether condition was present on admission or not
E–Exempt, unreported/not used, some facilities will leave these blank, others will use the letter “E”
Historically, the exempt POA diagnosis codes were listed in the guidelines of the ICD-10-CM book. However, in 2017 the AMA publication stopped printing the list of POA exempt diagnoses. For a list of exempt codes, please reference https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding.html. This information is available in several formats. The POAexemptCodes2017.zip is recommended, and from there the information can be viewed in word or excel format. The Add, Delete, and Revise files in that compressed folder are corrections and additions to the previous POA exempt list.
All codes listed in that reference are exempt from POA status. An “E” is used in the training program to represent exempt status. When using the 3M encoder, the software will mark all POA exempt codes for you. If coding by hand, this list will need to be referenced.
For more information on POA indicators please see Appendix I, Present on Admission Reporting Guidelines of the official ICD-10-CM guidelines https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf and appendix B, Reporting of the Present on Admission Indicator of the ICD-10-CM and ICD-10-PCS Coding Handbook.
Are POA Indicators Required on Outpatient Claims?
Inpatient care means that you are admitted to a hospital on the orders of a doctor. You become classified as an inpatient as soon as you are admitted.
Outpatient care covers many categories, including the ER, same day surgery, observation, and radiology, and more. Even with a hospital stay, your care might be considered an outpatient service. If your doctor orders observation of your condition or tests to help diagnose your condition while you are in the hospital, you can still officially be an outpatient.
For some outpatient surgeries, you may receive the surgery at a hospital but not be admitted. It is not until a doctor orders admission that you are considered inpatient and a medical coder needs to determine POA indicators.
Present on admission indicators are used as a form of recording for inpatient billing. POA indicators are not used or required on outpatient claims. However, conditions that develop during an outpatient encounter that lead toward an inpatient admission are considered POA.
What Is Considered Present on Admission?
This is a great question. It’s difficult to generalize. Some conditions are very obvious and can be easily identified, while others are not so simple. The easiest to determine are external conditions like broken bones or major cuts and injuries.If the patient came in with the condition, the POA is a yes. If the condition develops after the patient was admitted, the POA would be a no.
But some conditions are not as easy to see. It is important for coders to be clear on patients’ exact conditions to accurately reflect the care given at a hospital and to be able to select the correct POA indicator.
Learning medical coding can feel intimidating. When you are first shown the complexities and requirements involved, it’s difficult to know what’s going on. It sometimes feels like people are speaking a different language.
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