In the realm of medical coding and billing, accuracy is paramount. For inpatient admissions in general acute care hospitals, a critical component of this accuracy is the Diagnosis Present on Admission (POA) indicator. This indicator, mandated by the Centers for Medicare & Medicaid Services (CMS), ensures diagnoses are appropriately grouped for payment under the Medicare Severity Diagnosis Related Group (MS-DRG) system.
The POA indicator is applied to every diagnosis – both the principal diagnosis and any other diagnoses – reported on inpatient claims. Utilizing resources such as the UB-04 Data Specifications Manual and the ICD-10-CM Official Guidelines for Coding and Reporting is essential for correctly assigning POA indicators. These guidelines, updated annually and readily available, provide the framework for compliant and precise coding practices.
It’s crucial to understand that POA guidelines are not about when to code a condition, but rather how to apply the POA indicator to diagnoses that have already been coded according to official ICD-10-CM coding guidelines. After assigning the appropriate ICD-10-CM codes, the next step is to determine and append the correct POA indicator for each diagnosis.
Accurate and complete medical record documentation is the bedrock of effective diagnosis coding. Collaboration between healthcare providers and medical coders is indispensable to achieve this. Documentation from any qualified healthcare practitioner legally responsible for establishing a patient’s diagnosis is considered valid for POA indicator assignment.
When diagnosis codes are resequenced for transmission to CMS, it is imperative that the corresponding POA indicators are also resequenced accordingly. This responsibility falls upon providers, billing offices, third-party billing agents, and anyone involved in the data transmission process.
The Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule established the payment implications linked to the different POA indicator reporting options. The table below outlines these CMS POA Indicator Options and Definitions, which directly affect whether CMS will pay the CC/MCC DRG for certain Hospital Acquired Conditions (HACs).
| 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 conclusion, the accurate application of Diagnosis Poa indicators is not just a coding requirement, but a crucial element in ensuring appropriate reimbursement and reflecting the true clinical picture of inpatient care. Healthcare providers and coding professionals must maintain diligence and utilize available guidelines to ensure compliance and accuracy in POA reporting.
