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Accurately assign POA indicators with the right info

HIM Connection, September 29, 2009

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The present-on-admission (POA) indicator refers to conditions that are present at the time an order for inpatient admission occurs. Coders should report a POA indicator for a principal diagnosis, as well as any secondary diagnoses or E codes.

To assign POA, coders must rely on a treating physician’s documentation. Assuming physician documentation is accurate and complete, a coder can consider these tips when assigning a POA indicator:

• Look in the history and physical, as well as the ER physician documentation and admitting progress notes and orders. The cut-off point in determining whether the condition was POA is when the admit order was written.
• 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” when the condition is later confirmed or still qualified 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.

This tip was adapted from the HCPro book, The MS-DRG Training Handbook. For ordering information, visit the HCMarketplace.

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