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CMW Tip of the Week: Educate physicians on POA reporting

Case Management Weekly, October 8, 2008

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Last week’s tip on the timeline for querying physicians for POA reporting prompted several readers to respond. One reader was generous enough to provide a sample tool for querying physicians.

Gloryanne Bryant, BS, RHIA, RHIT, CCS, the senior director of systemwide coding and HIM compliance for Catholic Healthcare West, based in San Francisco, CA, says her facility uses a present-on-admission (POA) query tool for physicians when a POA diagnosis is unclear. The form explains that documentation clarification is required to meet federal and state (California requires O+POA reporting) POA compliance and prompts the physician to clarify the diagnosis by selecting from:

• Y = Yes, the condition was present on admission at the time of the order to admit to inpatient status
• N = No, the condition was not present on admission and it developed during the inpatient stay
• W = Clinically undeterminable by provider (physician)

Bryant says this form is usually completed at the time of the coding process and is well-received and understood by the physicians at her facility due to enhanced awareness, comprehensive education, and communication in regards to POA.

For a sample copy of the tool, or to share a tool of your own with other readers, email editor Julie McGinley at jmcginley@hcpro.com.

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