Health Information Management

Work with physicians to obtain clear-cut documentation for pressure ulcers

Briefings on Coding Compliance Strategies, December 1, 2008

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by Robert S. Gold, MD

Applying the present-on-admission (POA) indicator to pressure ulcers is no easy task.

Coders often question who can identify the POA indicator and how to handle situations in which the ulcer occurs or changes during the hospital stay. Well, let’s learn how we deal with it.

A patient may present to a hospital for observation or inpatient status treatment. The patient may first go to the ED, or he or she may be directly admitted to the hospital or transferred from another facility (e.g., day surgery, a nursing home, or another hospital). A physician in the ED, a physician or nurse in the outpatient department, or an admitting physician or nurse on the medical-surgical unit will see the patient. Someone must perform the initial evaluation.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Coding Compliance Strategies.

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