POA Reporting Guidelines
This article is designed to help facilitate the assignment of the Present on Admission (POA) indicator for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837 Institutional).
General Reporting Requirements
- All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information.
- Present on admission is defined as present at the time the order for inpatient admission occurs -- conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission
- POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.
- Issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider.
- If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported.
- Y - Yes, Present on Admission
- N - No, Not Present on Admission
- U - Unknown
- W - Clinically undetermined
- Blank - POA Exempt
Timeframe for POA Identification and Documentation
There is no required timeframe as to when a provider (per the definition of “provider” used in these guidelines) 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. In some cases it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission. Determination of whether the condition was present on admission or not will be based on the applicable POA guideline as identified in this document, or on the provider’s best clinical judgment.
If at the time of code assignment the documentation is unclear as to whether a condition was present on admission or not, it is appropriate to query the provider for clarification.
Assigning the POA Indicator
Condition is on the “Exempt from Reporting” list
Leave the “present on admission” field blank if the condition is on the list of ICD-10-CM codes for which this field is not applicable. This is the only circumstance in which the field may be left blank.
POA Explicitly Documented
Assign Y for any condition the provider explicitly documents as being present on admission. Assign N for any condition the provider explicitly documents as not present at the time of admission.
Conditions diagnosed prior to inpatient admission
Assign “Y” for conditions that were diagnosed prior to admission (example: hypertension, diabetes mellitus, asthma)
Conditions diagnosed during the admission but clearly present before admission
Assign “Y” for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred.
Diagnoses subsequently confirmed after admission are considered present on admission if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis, or constitute an underlying cause of a symptom that is present at the time of admission.
Condition develops during outpatient encounter prior to inpatient admission
Assign Y for any condition that develops during an outpatient encounter prior to a written order for inpatient admission.
Documentation does not indicate whether condition was present on admission
Assign “U” when the medical record documentation is unclear as to whether the condition was present on admission. “U” should not be routinely assigned and used only in very limited circumstances. Coders are encouraged to query the providers when the documentation is unclear.
Documentation states that it cannot be determined whether the condition was or was not present on admission
Assign “W” when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was present on admission
Chronic condition with acute exacerbation during the admission
If a single code identifies both the chronic condition and the acute exacerbation, see POA guidelines pertaining to combination codes.
If a single code only identifies the chronic condition and not the acute exacerbation (e.g., acute exacerbation of chronic leukemia), assign “Y.”
Conditions documented as possible, probable, suspected, or rule out at the time of discharge
If the final diagnosis contains a possible, probable, suspected, or rule out diagnosis, and this diagnosis was based on signs, symptoms or clinical findings suspected at the time of inpatient admission, assign “Y.”
If the final diagnosis contains a possible, probable, suspected, or rule out diagnosis, and this diagnosis was based on signs, symptoms or clinical findings that were not present on admission, assign “N”.
Conditions documented as impending or threatened at the time of discharge
If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were present on admission, assign “Y”.
If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were not present on admission, assign “N”.
Acute and Chronic Conditions
Assign “Y” for acute conditions that are present at time of admission and N for acute conditions that are not present at time of admission.
Assign “Y” for chronic conditions, even though the condition may not be diagnosed until after admission.
If a single code identifies both an acute and chronic condition, see the POA guidelines for combination codes.
Assign “N” if any part of the combination code was not present on admission (e.g., COPD with acute exacerbation and the exacerbation was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission)
Assign “Y” if all parts of the combination code were present on admission (e.g., patient with acute prostatitis admitted with hematuria)
If the final diagnosis includes comparative or contrasting diagnoses, and both were present, or suspected, at the time of admission, assign “Y”.
For infection codes that include the causal organism, assign “Y” if the infection (or signs of the infection) was present on admission, even though the culture results may not be known until after admission (e.g., patient is admitted with pneumonia and the provider documents pseudomonas as the causal organism a few days later).
Same Diagnosis Code for Two or More Conditions
When the same ICD-10-CM diagnosis code applies to two or more conditions during the same encounter (e.g. two separate conditions classified to the same ICD-10-CM diagnosis code): - Assign “Y” if all conditions represented by the single ICD-10-CM code were present on admission (e.g. bilateral unspecified age-related cataracts). - Assign “N” if any of the conditions represented by the single ICD-10-CM code was not present on admission (e.g. traumatic secondary and recurrent hemorrhage and seroma is assigned to a single code T79.2, but only one of the conditions was present on admission).
Whether or not the patient delivers during the current hospitalization does not affect assignment of the POA indicator. The determining factor for POA assignment is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission or not.
If the pregnancy complication or obstetrical condition was present on admission (e.g., patient admitted in preterm labor), assign “Y”.
If the pregnancy complication or obstetrical condition was not present on admission (e.g., 2nd degree laceration during delivery, postpartum hemorrhage that occurred during current hospitalization, fetal distress develops after admission), assign “N”.
If the obstetrical code includes more than one diagnosis and any of the diagnoses identified by the code were not present on admission assign “N”. (e.g., Category O11, Pre-existing hypertension with pre-eclampsia)
Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered present at admission and should be assigned “Y”. This includes conditions that occur during delivery (e.g., injury during delivery, meconium aspiration, exposure to streptococcus B in the vaginal canal).
Congenital conditions and anomalies
Assign “Y” for congenital conditions and anomalies except for categories Q00- Q99, Congenital anomalies, which are on the exempt list. Congenital conditions are always considered present on admission.
External cause of injury codes
Assign “Y” for any external cause code representing an external cause of morbidity that occurred prior to inpatient admission (e.g., patient fell out of bed at home, patient fell out of bed in emergency room prior to admission) Assign “N” for any external cause code representing an external cause of morbidity that occurred during inpatient hospitalization (e.g., patient fell out of hospital bed during hospital stay, patient experienced an adverse reaction to a medication administered after inpatient admission)
Source: CMS FY 2016 ICD-10-CM Official Guidelines, Appendix I
- POA exempt