Health Information Management

Tip: Use POA examples to educate physicians

CDI Strategies, October 1, 2007

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Having clear documentation at all points of care helps ensure that you'll have accurate present-on-admission (POA) reporting, says Caroline Piselli, program manager for ICD-10 and APR-DRGs for 3M Health Information Systems in Wallingford, CT.

 

And you can ensure clear documentation by working with physicians and providing them with examples and education regarding what you need. Giving physicians examples of documentation that clearly translates to the POA indicators (yes, no, uncertain, or clinically undetermined) will help physicians give coders what they need. Look for examples in the newest version of the ICD-9-CM Official Guidelines for Coding and Reporting which were effective October 1.



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