Present on Admission (POA) Indicator

This installment of “In the kNOW” will focus on the Present on Admission (POA) indicator which is used as a method of reporting whether a patient’s diagnoses are present at the time they are admitted to a facility.  We’ll look at a few scenarios to determine the correct reporting of POA and the impact reporting can have on reimbursement.  But first, let’s review the background of POA reporting. 

It was the Deficit Reduction Act of 2005 that required POA reporting as a method of reducing cost and improving the quality of care.  Hospitals reimbursed under the Inpatient Prospective Payment System (IPPS) have been mandated to report POA indicators for principal and secondary diagnoses since October 1, 2007.  When a POA indicator of “N” (no) is reported for any condition on the Hospital-Acquired Condition (HAC) list, reimbursement will not be impacted by that diagnosis. 

The Hospital-Acquired Condition list was created using the following criteria:

• Conditions are high cost, high volume, or both
• Conditions result in higher payment because they are assigned to MS-DRGs due to presence as secondary diagnosis
• Use of evidence-based guidelines might reasonably have prevented the conditions from occurring

Today, there are fourteen categories of conditions on the HAC list which are as follows:

• Foreign Object Retained After Surgery 
• Air Embolism 
• Blood Incompatibility 
• Stage III and IV Pressure Ulcers 
• Falls and Trauma 
• Fractures 
• Dislocations 
• Intracranial Injuries 
• Crushing Injuries 
• Burn 
• Other Injuries 

• Manifestations of Poor Glycemic Control 
• Diabetic Ketoacidosis 
• Nonketotic Hyperosmolar Coma 
• Hypoglycemic Coma 
• Secondary Diabetes with Ketoacidosis 
• Secondary Diabetes with Hyperosmolarity

• Catheter-Associated Urinary Tract Infection (UTI) 
• Vascular Catheter-Associated Infection 
• Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG)
• Surgical Site Infection Following Bariatric Surgery for Obesity 
• Laparoscopic Gastric Bypass 
• Gastroenterostomy 
• Laparoscopic Gastric Restrictive Surgery 

• Surgical Site Infection Following Certain Orthopedic Procedures 
• Spine 
• Neck 
• Shoulder 
• Elbow

• Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED) 
• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures: 
• Total Knee Replacement 
• Hip Replacement

• Iatrogenic Pneumothorax with Venous Catheterization

The definition of present on admission is that the condition is present at the time the order for inpatient admission is given.  Conditions originating in an outpatient encounter, for example the emergency room prior to admission, will be considered as POA.  When a coder cannot determine if a condition is POA or not, a query should be initiated requesting clarification from the provider. 

The POA indicators are:
    Y-present at the time of inpatient admission
    N-not present at the time of inpatient admission
    U-documentation is insufficient to determine if condition is present on admission
    W-provider is unable to clinically determine whether condition was present on admission or not

Let’s take a look at how assignment of the POA indicator can impact reimbursement.  In this example, we have a patient with hypertensive CKD stage 3 as the principal diagnosis.  With no further diagnoses reported, this will result in MS-DRG 684 Renal Failure w/o CC/MCC.  Now if the patient also had a stage 3 pressure ulcer of the left heel, you should get an Ungroupable DRG since this is a HAC and must have a POA designation in order for the MS-DRG to be correctly calculated.  Let’s look at the comparison when the various POA indicators are used.

POA Indicator    MS-DRG                                                   Relative Wgt   Reimbursement
Y or W              MS-DRG 682: Renal Failure w/MCC            1.4843            $8,214.72
N or U               MS-DRG 684: Renal Failure w/o CC/MCC    0.6284            $3,539.92

As seen above, there is a $4,674.80 difference in reimbursement based on whether the pressure ulcer was present on admission and can be used an MCC (Y or W) versus the same code not qualifying as an MCC because the POA indicator shows that the condition originated after admission (N or U). 

There is a list of conditions that are exempt from POA reporting that can be found at https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.html.  All other conditions are required to be identified by one of the POA indicators above.  Let’s examine POA assignment for a few examples.

A patient has choanal atresia  Q30.0.   This condition is exempt from reporting as it is a congenital condition.  This may be signified as “E” in the encoder, but reported with a “1” on UB-04 billing form. 

A patient is diagnosed with chronic pancreatitis five days after admission.  The POA assignment is “Y” as chronic conditions are considered POA even though the diagnosis does not happen until post-admission.

A patient with epilepsy is admitted and develops status epilepticus on day 3.  The POA assignment for the combination code identifying the epilepsy with status epilepticus is “N” since not all components of the condition specified in the code were present at the time of admission.  In this case, the status epilepticus didn’t occur until after admission.

Further examples and explanations can be found in Appendix I. Present on Admission Reporting Guidelines in the ICD-10-CM code book or on-line.    

Now you are in the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.