Health Information Management

Present on admission indicator now in effect

CDI Strategies, October 4, 2007

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Clinical documentation improvement specialists have to worry about more than just improving the quality of the medical record during a patient's stay: They now must take extra care to observe any signs or symptoms in the record indicating secondary diagnoses that may be present on the patient's admission.

Beginning October 1 of this year, CMS requires hospitals to complete a present on admission (POA) indicator for every diagnosis on inpatient acute care hospital claims. On April 1, 2008, if hospitals do not report a valid POA code for each diagnosis on the claim, CMS will return the claim to the hospital, which must resubmit the claim with correct POA information.

For more information on the present on admission indicator, view the following CMS transmittals:

http://www.cms.hhs.gov/transmittals/downloads/R1240CP.pdf

http://www.cms.hhs.gov/transmittals/downloads/R289OTN.pdf



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