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Tip: Assign POA carefully, based on treating practitioner's documentation involved in patient's care

CDI Strategies, May 15, 2008

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In the CDI and coding community a number of questions continue to exist regarding CMS’ definitions of physicians and other healthcare practitioners, as they relate to assigning Present on Admission (POA) indicators. POA guidelines state that any “provider” involved in the care of a patient is acceptable to support documentation of whether a condition was POA. However, some problems exist with the fact the term “provider,” by CMS’ definition, is considered a physician or other healthcare practitioner. 

It is important to remember that, first and foremost, each diagnosis must meet the criteria for code assignment based on the UHDDS definitions before you consider which POA to report. Based on the coding guidelines, generally the source for code assignment is based on a treating practitioner’s documentation directly involved in the patient’s care. Generally, it is not appropriate to assign a diagnosis code based solely on a clinical nurse specialist, psychologist, or social workers’ note without further substantiated documentation by a treating physician. PAs and NPs can sometimes be valid documentation for code assignment but hospital policies may vary. The only exception to this rule is that coders can abstract BMI codes (V85) from a dietitian’s note per the AHA Coding Clinic, Fourth Quarter, 2005, but note that BMI codes are exempted from POA assignment. 

In short, you cannot assign POA information solely out of one of the “healthcare practitioners” notations.  Most of those listed require further corroboration in order to first meet the criteria for assignment of an ICD-9 diagnosis code for the condition. At that point, the appropriate POA should be assigned based on the physicians’ documentation.

(Shannon McCall, RHIA, CCS, CPC-I, director of HIM and coding for HCPro, Inc., in Marblehead, MA, provided this tip)

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