Health Information Management

Monitor staff performance and physician documentation to ensure POA compliance

JustCoding News: Inpatient, October 14, 2009

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Just because coders have been reporting the present-on-admission (POA) indicator for nearly two years doesn’t mean HIM directors should assume their facilities are in compliance.

“There’s always going to be room for improvement, but I think overall, we’re doing very well at capturing that data,” says Rob Holdenwang, RHIA, CPUR, senior manager of acute care consulting services at 3M Health Information Systems in Atlanta.

Assignment of the POA indicator can be challenging for coders, particularly when clinical scenarios are complex, Holdenwang says. This occurs when patients delay treatment and present to the hospital with multiple complicating conditions, such as congestive heart failure exacerbation, pneumonia, and chronic obstructive pulmonary disease, he says, adding that combing through clinical information to assign the correct POA indicator is certainly a daunting task.

Where does this leave coders? Desperately hoping for a detailed and thorough history and physical that includes a full and complete body assessment within 24 hours after admission, Holdenwang says. Past medical history can be problematic because physicians often underdocument currently existing conditions or those that have existed in the past, he says.

“The surgeon focuses on the surgery piece but neglects to manage the medical piece,” Holdenwang says. Congestive heart failure can be particularly problematic when physicians document the condition only during its acute stage. “The physician won’t even mention it if it’s compensated somehow,” he says.

Provide physician education
A consultant audits POA indicator assignment monthly at McAlester (OK) Regional Health Center, a 198-bed facility, says Sheila Zachary, RHIA, a coding supervisor at the facility. Insufficient physician documentation—not coder error—is the culprit with respect to incorrect POA indicator assignment, she says.

“Hospitalists come and go,” says Zachary, noting that the hospital currently has many new providers who need education on the topic. She hopes to incorporate formal POA education into new physician orientation.

The consulting company provides some of the ongoing physician education, and Zachary provides reminders when she speaks at medical staff meetings.

The consulting company also provides a POA query form that prompts the hospital’s physicians to indicate whether a condition was POA. The form is separate from other query forms and may be initiated by any case manager or the clinical documentation improvement specialist, says Connie Davis, RN, BSN, the hospital’s director of support services and quality.

Audit and monitor POA data
Ultimately, regularly auditing and monitoring POA indicator assignment is the only way to track progress and ensure compliance, Holdenwang says. Begin with a high-level department-wide audit that establishes a baseline by tracking data for six months to determine trends. This will enable you to determine how often staff members report each of the five indicators. Pay close attention to the U indicator because it denotes insufficient documentation and should be avoided to the extent possible.

McAlester’s coders rarely report the U indicator because they are required to query physicians before finalizing bills, Zachary says.

Be especially mindful of U and N indicators for decubitus ulcers because under-documentation is common, Holdenwang says. “You really want to make sure that it’s documented in the medical record … so that your hospital doesn’t take the hit when it happened in a nursing home,” he says.

Look for indicator patterns related to high-risk/problem areas, acute or chronic conditions, combination codes, or rule-out diagnoses. Focus on congestive heart failure and diabetes along with decubitis ulcers, says Holdenwang. Work with medical staff members to provide more detailed documentation and ask physicians to provide clinical education to coders regarding certain disease processes. This will better equip coders to assign indicators or query for more information when necessary.

Once you’ve conducted a high-level audit, consider auditing individual coders, Holdenwang says. Establish a baseline for each coder and track and trend each indicator the coder reports.

It’s important to review all indicators, not just the ones that affect payment, he says. “It’s also a good idea to track movement of the indicators. This may reveal that some coders are more diligent than others in capturing that indicator,” he says.

Audit data may also reveal that certain coders need more education. “What is each coder’s skill set in terms of applying the POA, and what other education can you provide to them?” Holdenwang asks.

Follow these guidelines when auditing coders:

  • Ensure a fair, yet manageable, sample size based on the total number of records assigned to each coder. Include a representative sampling of patients by case and payer mix.
  • Consider reviewing records daily, rather than at the end of the month or quarter, so that the task does not become burdensome.
  • Always track the Y indicator because this is important with respect to providing coders positive feedback.

Editor’s note: E-mail Holdenwang at 

E-mail Zachary at

E-mail Davis at

This story was originally published in the September issue of Medical Records Briefing.

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