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Pop quiz: Querying for the POA indicator

CDI Strategies, September 18, 2008

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Scenario: A physician admits a patient because of an acute gastric ulcer. The attending general internist requests a consultation from a gastroenterologist on day two of the admission. The purpose of the consultation is to evaluate the ulcer and a recent drop in hematocrit. The gastroenterologist documents in his findings that the patient has an acute gastric ulcer with active bleeding. During day three of the admission, the gastroenterologist performs an esophagogastroduodenoscopy that confirms the presence of the acute gastrointestinal (GI) ulcer with hemorrhage. The attending physician documents in the discharge summary that the principal diagnosis is acute gastric ulcer.

Question: Is it appropriate to query the physician regarding whether the GI bleeding was POA, or can you simply report a POA indicator based on the documentation? If you can report an indicator, which one should you report?

Answer: In this case, query the physician. The acute gastric ulcer with hemorrhage maps to a combination code, 531.00, and there is no indication on the internist's history and physical that the ulcer was bleeding at the time of admission. Per the POA guidelines, if all elements of a combination code are not POA, you should report an N indicator. Therefore, query the attending physician for clarification so you can accurately report the diagnosis code as well as the POA indicator.

If the internist states that this information was obvious from the clinical documentation in the medical record, advise him or her that the ICD-9-CM coding rules and conventions bind all coders and providers to code only from explicit physician documentation and that failure to ascertain whether the bleeding was POA would affect his or her public profile, calling attention to the fact that this may be deemed as an hospital acquired condition (HAC) or complication. The financial impact for the attending physician is that HACs are a factor that some insurance companies use in their tiered-network methodologies that increase patient copayments for unfavorably-tiered physicians.

Editor's note: The above quiz was excerpted from The Present on Admission Training Handbook: Answers to Your Coding and Documentation Questions. To learn more, click here.

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