For proper grouping of diagnoses into MS-DRGs, the Centers for Medicare & Medicaid Services (CMS) mandates the use of Present on Admission (POA) indicators for all diagnoses reported on inpatient claims in general acute care hospitals. To ensure accurate reporting, it is essential to consult the UB-04 Data Specifications Manual and the ICD-10-CM Official Guidelines for Coding and Reporting. These resources guide the assignment of POA indicators for each principal and other diagnosis code on UB-04 and 837 Institutional claim forms. The official coding guidelines are updated annually and can be found within the comprehensive ICD-10-CM files.
It is crucial to understand that this information supplements, and does not replace, the official ICD-10-CM guidelines. The POA indicator guidelines are specifically designed to guide the application of POA indicators to already assigned diagnosis codes, based on Sections I, II, and III of the official coding guidelines, rather than dictating when a condition should be coded. After ICD-10-CM codes are assigned according to these official guidelines, the POA indicator must be applied to every coded diagnosis.
Accurate and complete documentation is paramount for effective coding and reporting. As emphasized in the Introduction to the ICD-10-CM Official Guidelines, collaboration between healthcare providers and coders is vital for ensuring the completeness and accuracy of medical records, code assignments, and reporting of diagnoses and procedures. Documentation from any qualified healthcare practitioner legally responsible for establishing a patient’s diagnosis is acceptable.
It is also important to note that any resequencing of diagnosis codes prior to transmission to CMS must also include a corresponding resequencing of the POA indicators. This responsibility falls upon the provider, their billing office, third-party billing agents, and anyone involved in data transmission.
The Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule (CMS-1390) detailed the payment implications for each POA indicator reporting option. The table below outlines the CMS POA Indicator Options and Definitions, which are critical for understanding these implications.
CMS POA Indicator Options and Definitions
| Code | Reason for Code |
|---|---|
| Y | Diagnosis was present at time of inpatient admission. CMS will pay the CC/MCC DRG for selected Hospital Acquired Conditions (HACs) coded as “Y”. |
| N | Diagnosis was not present at time of inpatient admission. CMS will not pay the CC/MCC DRG for selected HACs coded as “N”. |
| 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 coded as “U”. |
| 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 coded as “W”. |
| 1 | Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, but blanks are not acceptable for electronic submissions. CMS will not pay the CC/MCC DRG for selected HACs coded as “1”. Importantly, the “1” POA Indicator should not be used for codes on the HAC list. Refer to the Official Coding Guidelines for ICD-10-CM for a comprehensive list of POA exempt codes. |
