Accurate medical coding is crucial for healthcare providers, especially concerning inpatient admissions. For every diagnosis reported during an inpatient stay at general acute care hospitals, the Centers for Medicare & Medicaid Services (CMS) mandates the use of a Present on Admission (POA) indicator. This system ensures proper grouping of diagnoses into the correct Medicare Severity Diagnosis Related Groups (MS-DRGs) and affects hospital payments, particularly concerning Hospital Acquired Conditions (HACs).
To correctly assign POA indicators, it’s essential to consult both the UB-04 Data Specifications Manual and the ICD-10-CM Official Guidelines for Coding and Reporting. These resources provide the necessary guidance for applying POA indicators to both the principal diagnosis and other diagnoses reported on claim forms, whether UB-04 or 837 Institutional. The official coding guidelines are updated annually and are readily accessible via CMS resources.
It’s important to understand that POA guidelines are not intended to dictate when a condition should be coded. Instead, they guide how to apply the POA indicator to diagnoses that have already been coded according to official ICD-10-CM coding guidelines (Sections I, II, and III). The POA indicator assignment is a step that follows the accurate assignment of ICD-10-CM codes.
Effective and precise documentation, code assignment, and reporting require collaboration between healthcare providers and medical coders. Complete and consistent documentation within the medical record is paramount. This documentation should come from any qualified healthcare practitioner legally responsible for establishing the patient’s diagnosis. This collaborative approach ensures the integrity of the coding process and accurate representation of the patient’s clinical status upon admission.
Furthermore, it’s critical to maintain the integrity of the POA indicators even if diagnosis codes are resequenced before transmission to CMS. Any reordering of diagnosis codes must be accompanied by a corresponding resequencing of the POA indicators to maintain data accuracy.
The Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule (CMS-1390) established the payment implications tied to each POA indicator reporting option. Understanding these implications is vital for hospital revenue cycle management. The table below outlines the CMS POA Indicator Options and Definitions, detailing how each indicator affects payment, especially in the context of HACs.
CMS POA Indicator Options and Definitions
| Code | Reason for Code | Payment Implications for HACs |
|---|---|---|
| Y | Diagnosis was present at time of inpatient admission. | CMS will pay the CC/MCC DRG for selected HACs. |
| N | Diagnosis was not present at time of inpatient admission. | CMS will not pay the CC/MCC DRG for selected HACs. |
| U | Documentation insufficient to determine if the condition was present at the time of inpatient admission. | CMS will not pay the CC/MCC DRG for selected HACs. |
| W | Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. | CMS will pay the CC/MCC DRG for selected HACs. |
| 1 | Unreported/Not used. Exempt from POA reporting. | CMS will not pay the CC/MCC DRG for selected HACs. (Should not be applied to HAC list codes) |
In summary, the POA indicator system is a critical component of inpatient medical coding and billing. Accurate application of POA indicators, guided by official guidelines and robust documentation, ensures appropriate reimbursement and reflects the patient’s condition at the time of admission. This is relevant across all diagnoses, including those related to complex care scenarios like palliative care, where accurately reflecting the patient’s condition on admission is vital for appropriate care management and billing. Understanding and correctly utilizing POA indicators is therefore essential for healthcare providers and coding professionals.
