Health Information Management

Dig deeply into documentation whenever you assign the POA indicator

HIM-HIPAA Insider, March 8, 2011

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You’re coding a record, and the documentation of a patient’s stage III pressure ulcer isn’t clear enough for you to determine whether the ulcer is POA. More importantly, what do you do?

Unfortunately, some coders simply default to POA indicator “N” instead of querying the physician, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent HIM consultant in Madison, WI. However, the goal should be reducing the number of “Ns”—not accepting them as fact, Krauss says.

“Every case that’s not POA should be reviewed by a physician,” he says. “You may be sending a wrong signal to Medicare, and the immediate effect is that you’re forgoing reimbursement to which you may be entitled.”

Note: To read more, view the February issue of Briefings on Coding Compliance Strategies.

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