Health Information Management

Ask the expert: Can you explain the role that coders play in educating physicians about the present on admission indicator?

HIM Connection, August 12, 2008

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With their understanding of the present on admission (POA) guidelines as published in Coding Clinic and the updated ICD-9-CM coding guidelines (effective October 1), coders are well-suited to educate ED and attending physicians about POA indicators and their documentation requirements.

Coders should tailor their education by explaining how accurate POA reporting is predicated on the complete and accurate medical record documentation that physicians provide. Emphasize that only physicians or others who are officially licensed to assign diagnoses are empowered to make these determinations—not the coding or other nonqualified hospital staff.

Coders should also explain to physicians that reporting accurate and complete POA administrative data benefits everyone because it supports the high quality of care that physicians provide at the facility.

Finally, coders should emphasize that the reputations of the hospital as well as the physicians are at stake with the POA initiative. These efforts effect long-lasting change in provider documentation behavior patterns.

Editor’s note: This article was excerpted from The Present on Admission Training Handbook: Answers to Your Coding and Documentation Challenges. For more information, visit www.hcmarketplace.com/prod-6455.html.



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