Inpatient care coding relies heavily on precision and adherence to official guidelines to ensure accurate billing and reimbursement. A critical aspect of this process is the application of Present on Admission (POA) indicators. These indicators are essential for grouping diagnoses into the correct Medicare Severity Diagnosis Related Groups (MS-DRGs), as mandated by the Centers for Medicare & Medicaid Services (CMS) for all inpatient admissions in general acute care hospitals. To correctly assign POA indicators, healthcare professionals must consult the UB-04 Data Specifications Manual and, most importantly, the ICD-10-CM Official Guidelines for Coding and Reporting. These guidelines are updated annually and are crucial for assigning the POA indicator to both the principal diagnosis and any other diagnoses reported on claim forms, whether UB-04 or 837 Institutional. The comprehensive ICD-10-CM files, including the Official Guidelines for each fiscal year, are readily accessible through resources provided by CMS.
It’s vital to understand that resources like this website serve as supplementary tools and should not replace the comprehensive guidance found within the main body of the ICD-10-CM Official Guidelines for Coding and Reporting. The purpose of POA indicator guidelines is not to dictate when a condition should be coded, but rather to provide clear instructions on how to apply the POA indicator to the final set of diagnosis codes. This application must always be in accordance with Sections I, II, and III of the official coding guidelines. The POA indicator assignment is a step that occurs after the appropriate ICD-10-CM codes have been determined and assigned.
Accurate and complete documentation is the bedrock of effective coding and reporting. As emphasized in the Introduction to the ICD-10-CM Official Guidelines for Coding and Reporting, a collaborative effort between healthcare providers and coders is indispensable. This partnership ensures that documentation is not only complete but also accurate, facilitating precise code assignment and reporting of both diagnoses and procedures. The medical record documentation, provided by any qualified healthcare practitioner legally responsible for establishing a patient’s diagnosis, is paramount.
Furthermore, it is the responsibility of the provider, their billing office, third-party billing agents, and anyone involved in data transmission to CMS to ensure that if diagnosis codes are resequenced for transmission, the POA indicators are also resequenced accordingly. This maintains data integrity and accurate representation of the patient’s condition upon admission.
The Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule (CMS-1390) has clearly defined the payment implications associated with each POA Indicator reporting option. Understanding these implications is crucial for financial accuracy in inpatient billing. The CMS POA Indicator Options and Definitions table below outlines these options in detail:
| Code | Reason for Code |
|---|---|
| Y | Diagnosis was present at time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as “Y” for the POA Indicator. |
| N | Diagnosis was not present at time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “N” for the POA Indicator. |
| 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 those selected HACs that are coded as “U” for the POA Indicator. |
| 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 those selected HACs that are coded as “W” for the POA Indicator. |
| 1 | Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “1” for the POA Indicator. The “1” POA Indicator should not be applied to any codes on the HAC list. For a complete list of codes on the POA exempt list, see the Official Coding Guidelines for ICD-10-CM. |
In summary, adhering to official coding guidelines, particularly the ICD-10-CM guidelines and the UB-04 specifications, is paramount for accurate inpatient care coding. The POA indicators play a vital role in appropriate reimbursement and reflect the patient’s condition at the time of admission. Consistent and collaborative documentation practices, coupled with a thorough understanding of POA indicator definitions and their payment implications, are essential for all stakeholders involved in the inpatient billing process.
