A Present On Admission (POA) indicator is required on all diagnoses code for inpatient setting. The exception to this rule is the admitting diagnosis. A POA indicator is used to indicate if the condition was present on admission.
There are five different POA 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 is present on admission
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 diagnoses codes were listed in the guideline 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 ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2017/. 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.
For a full list of POA indicators please see POAexemptcodes2017. The Add, Delete, and Revise files are corrections and additions to last year’s POA exempt list. All codes listed in this reference are Exempt from POA status, an “E” is used in the training program to represent exempt status. When using the 3M encoder, the POA tool will automatically fill the exempt status codes. 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/2017-ICD-10-CM-Guidelines.pdf and appendix B, Reporting of the Present on Admission Indicator of the ICD-10-CM and ICD-10-PCS Coding Handbook.