Tip: Look for confirming diagnoses when reporting the POA indicator
HIM Connection, February 25, 2008
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Before you report a present on admission (POA) indicator, look for confirming diagnoses. Perhaps the physician documented a sign or symptom on admission, but didn't render a diagnosis until two or three days later. The physician may have documented a diagnosis as "possible" or "probable," but didn't confirm it until later in the progress notes. Only code a diagnosis listed as "possible" or "probable" if the physician later confirms it still qualifies it as uncertain at the time of discharge. Since the diagnosis is based on signs or symptoms that were POA, the coder would assign a "yes" indicator. Note that an uncertain diagnosis would be POA only when that diagnosis had related signs or symptoms that were present at the time of admission. Otherwise, if the signs and symptoms developed after the physician order, the diagnosis is not POA.
Editor's note: This tip was adapted from HCPro's MS-DRG Training Handbook. For more information, visit www.hcmarketplace.com/prod-6201.html or call 800/650-6787.
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