Monday, August 27, 2018

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  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.

Wednesday, August 22, 2018

ICD-10-PCS Root Operations Crossword Puzzle

It's that time of year!  The start of the school year.  Homework!  Studying!  Exams!  In the spirit of the new school year, test YOUR coding knowledge with the below crossword puzzle on ICD-10 PCS Root Operations.  Click HERE to print the crossword!!  Click HERE for the answers.

4.  free body part from physical constraint by cutting/use of force
6.  joining portions of articular body part to immobilize
7.  expanding orifice/lumen of tubular body part
9.  move to normal/other suitable location all or part of a body part
12. cutting off all or portion of upper/lower extremities
13. correct malfunctioning device/position of displaced device
15. putting in appliance to monitor/assist/perform/prevent function 
    but not take the place of a body part
16. visual/manual exploration of body part
17. putting back all or part of a separated body part to normal/
    other suitable location
18. complete closing of an orifice/tubular body part
19. taking/letting out fluids/gases from a body part
22. cutting out/off a portion of a body part
24. cutting out/off without replacement all of a body part

1.  stopping/attempting to stop postprocedural/acute bleeding
2.  cut into body part to separate or transect
3.  locate route of passage of electrical impulses/functional areas 
    in a body part
4.  taking out/off a device
5.  taking/cutting out solid matter from a body part
6.  breaking solid matter in a body part into pieces
8.  move, without taking out, all/part of a body part to take 
    over function of all/part of a body part
10. restoring body part to normal structure and function
11. altering route of tubular body part
14. replacing device on same body part without cutting skin
20. modifying natural anatomic structure of body part without 
    impact to functionality
21. pulling/stripping out/off all or part of a body part by 
    use of force
23. putting in material to reinforce/augment function of a portion 
    of a body part

Monday, August 13, 2018

OHIMA Board President’s Message (2018-19)

Hello and welcome!  I am excited to serve as President of the Ohio Health Information Management Association (OHIMA). OHIMA’s strategic planning provides us with opportunities to partner with members of our community this upcoming year to accomplish the goals and objectives we’ve set. Together, with your help, I know we can accomplish great things in 2018-2019.

As you may know, the American Health Information Management Association (AHIMA), our national Association, has new leadership. Dr. Wylecia Wiggs Harris now serves as the Chief Executive Officer of AHIMA.  AHIMA has introduced the “2018-2022 Strategic Objectives” to accomplish the vision under the leadership of Dr. Wiggs Harris which is “improving health through trusted information.”

I’d like to take this opportunity to highlight some key points of AHIMA’s strategic objectives so you will have an idea of how together we can help the HIM profession to “Transform healthcare by leading HIM, Informatics, and Information Governance.”

Technological advancements throughout the healthcare industry make it necessary to expand the roles of HIM professionals.  OHIMA, in partnership with AHIMA, is working to prepare our members for the HIM roles of the future.

At the end of 2017, AHIMA released the “Informatics Toolkit for Health Informatics and Information Management Professionals.”  It has been noted in the healthcare industry that HIM professionals bring unique and exceptional skills to roles in data analytics.  For that reason, one objective of AHIMA is to expand the number of new and current members who have a data analytics role as their primary job.

HIM professionals drive the data being collected by healthcare organizations.  So, it goes without saying that HIM professionals are in a position to support healthcare organizations with the management of collected data.  AHIMA wants to take it a step further by equipping HIM professionals with expertise in the use of Information Governance tools to transform the data into information to assist in achieving the strategic objectives of healthcare organizations.  AHIMA strives to increase the adoption of Information Governance practices through the use of the “AHIMA Information Governance Adoption Model” and the “AHIMA Information Governance Toolkit 3.0.”

The OHIMA membership is well-prepared to advance these strategic objectives through partnership and participation.  We are nationally recognized as the Component State Association (CSA) with outstanding participation from its membership!  I encourage you to share your ideas and suggestions with us to help you and our membership grow as HIM professionals.  Feel free to reach out to me at the email address below if you would like to share your thoughts.  Please partner with me as we work to advance the strategic objectives established by AHIMA to realize the goal of ensuring “the right information is delivered to the right person and the right time.”


Krystal Phillips, RHIA, CHTS-IS 
OHIMA Board President 2018-19