Health Information Management

Unclear documentation fuels ongoing challenges in assigning appropriate POA indicator

JustCoding News: Inpatient, February 1, 2012

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The task of assigning the appropriate present on admission (POA) indicator for various conditions is still fraught with a number of challenges—many of which stem from problems coders have in obtaining clear, explicit physician documentation. Gleaning the necessary details from the records can be a daunting task in and of itself, and then inconsistencies among various physicians makes assigning POA indicators that much harder.

Analyze documentation at point of entry

Look first to the history and physical (H&P) to see whether there is any indication that the condition was POA. In addition, look at the documentation at the patient’s point of entry—the ED record or gastrointestinal lab, for example, says Colleen Stukenberg, MSN, RN, CCDS, CMSRN, clinical documentation management professional at FHN Memorial Hospital in Freeport, IL, and former board member for the Association of Clinical Documentation Improvement Specialists (ACDIS).

“Did the patient undergo a procedure and then get admitted right after that?” she says. “Examine the documentation regarding labs and diagnostics around the time frame of the first point of entry.”

For more complicated cases, it can be difficult to assign the appropriate indicator for conditions that clinicians may initially overlook due to the urgency of another condition.

For example, consider a patient who comes in with congestive heart failure (CHF). The physician listens to the lungs and heart and watches telemetry monitoring. However, the physician neglects to document that the patient also has a decubiti on his or her left heel. A nurse documents the decubiti after an examination the following day. In this case, because the physician did not document the decubiti in the H&P or the ED notes, the coder must inquire whether it was POA.

Look for supporting data, Stukenberg says. Could the patient develop that stage of decubiti on the heel within a few hours? “Coders need to look for clinical cues. And what are the time frames for those clinical cues; when do those normally develop for that condition?” Stukenberg says.

Know rules regarding combination codes

One of the common mistakes coders make regarding POA indicator assignment relates to combination codes. If any one part (i.e., condition) of a combination code was not POA, then N (No) is the appropriate POA indicator, says Donna D. Wilson, RHIA, CCS, CCDS, senior director at Compliance Concepts, Inc., in Wexford, PA, and a current ACDIS board member. Some coders still erroneously assign a Y (Yes) just because one of the two conditions indicated in the combination code was POA. Refer to the ICD-9-CM Official Guidelines for Coding and Reporting, Appendix I: POA Reporting Guidelines.

So even when the documentation in the record states “patient has a gastric ulcer with a bleed,” if the patient started bleeding hours after the admission, POA indicator N is appropriate, meaning that the patient did not have this condition at the time of admission, Wilson says.

One physician may document “gastric ulcer with bleed” in the H&P, but upon closer examination, clinical indications show that the patient is not currently bleeding.

“We have to go through the record and ask –Are they actually bleeding during this admission?” says Wilson. “The patient may be clinically stable with normal Hemoglobin/Hematocrit (H/H) levels and after reviewing the medical record and/or querying the physician, you may determine that the acute bleed occurred months prior to this current admission.”

Another example would be a patient who is dehydrated on admission with normal sodium levels. Later on during the hospital stay, the patient develops low levels of sodium in the blood (i.e., hyponatremia). There is a combination code for dehydration with hyponatremia (ICD-9-CM code 276.1). Because the hyponatremia did not develop until after admission, assign the POA indicator of N for code 276.1 (dehydration with hyponatremia).

Look for clinical cues

Acute exacerbation of CHF is another challenging diagnosis to assign the correct POA indicator. “Oftentimes, when querying physicians, we get unanswered or ambiguous responses,” Wilson says.

“Coders and CDI [clinical documentation improvement] specialists are medical record documentation detectives,” Wilson says. “We struggle with conflicting documentation particularly with so many physicians documenting in the medical record.”

Some large group physician practices have developed the hospitalist approach to hospital rounding. Dr. A may be on call at the hospital Monday through Friday, and Dr. B. relieves Dr. A. on Saturday as the attending physician on the case. On the day of admission, Dr. A. may have documented chronic CHF (Monday–Friday) and Dr. B. starts documenting acute CHF exacerbation (on Saturday). “This is when querying is vitally important,” Wilson says.

“You may also look for clinical cues to indicate the acuity level of the CHF and to determine whether the condition was acute at the time of admission,” Wilson says “Review the BNP (B-type Natriuretic Peptide) level, chest x-rays, medication administered/dosage, edema, and other clinical indications of CHF.”

POA indicator assignment for pneumonia is also often challenging, Wilson says. Documentation may clinically support pneumonia on admission, but there may be no physician documentation of pneumonia until days after admission.

Also, a patient could come in with a normal chest x-ray. But then within 24–48 hours after being hydrated, now the chest x-ray shows infiltrates. Was the pneumonia POA? “There are cases in which the chest x-ray would not show positive until the patient was hydrated,” Stukenberg says.

“When in doubt, query the physician,” Wilson says.

You also have to consider what is this patient’s normal history? “A radiologist may document an abnormal x-ray because he or she does not have a prior film to compare it to,” Stukenberg says. “But the patient’s physician, who knows this person’s history, realizes that this x-ray result—while abnormal for some—is chronically normal for this particular patient and not an acute finding.”

In other words, this is not an acute situation—It’s a chronic condition for that person and therefore his or her norm. “A patient’s history can give us context for the current admission,” Stukenberg says.

Don’t make assumptions regarding sepsis

Many times coders do not query physicians for clarification of sepsis, Wilson says.

Conflicting documentation within the progress notes can increase confusion. One progress note may state urosepsis and two days later a diagnosis of sepsis appears. There may be clinical indications to suggest sepsis was POA; however, coders need to thoroughly review the medical record and query when appropriate, Wilson says.

A patient could present with a UTI, but the documentation seems to indicate that the patient has a more serious condition than a UTI alone. Perhaps at the time of admission, you do not have information in the record to indicate an elevated white count or bands or positive blood cultures, for example, but you do have this data a couple hours later.

“So the big challenge involves knowing the time frames when certain diagnostics would become abnormal as they pertain to specific conditions. Also what would a person look like for a certain condition,” Stukenberg says. “Is his presentation and diagnostics equivalent to the documented condition, or is there more going on with the patient? Does the clinical picture match the documentation in the chart?”

Are the results close enough to the time of admission to be able to count it as POA? Or should the coder report that the patient did not present with these symptoms?

“I try to encourage our clinicians, if you find it, document it—even if it’s not part of their overall condition,” Stukenberg says. “You don’t know what it will turn into 24 hours down the line.”

Look for information in the chart that shows a condition was POA, but it wasn’t documented as such, Stukenberg says. This could include abnormal labs or chest x-rays, which could indicate a UTI or pneumonia, but the clinician does not document these conditions until days later. “So that’s one of the challenges—just the lack of thorough documentation when the person first enters the system.”

Understand common mistakes related to pregnancy cases

Coders also sometimes make mistakes in POA indicator assignment for pregnancy cases. For example, if a mother comes in and is pregnant, and we’re trying to determine whether the preeclampsia is POA or whether the patient moved into preeclampsia during admission.

A patient could come in with high blood pressure, and this condition escalates to preeclampsia. A query may be appropriate to determine whether the high blood pressure was a symptom of some other problem with the pregnancy or if the documentation is clear that preeclampsia is the cause of the high blood pressure, the POA indicator Y could be applicable, Wilson says.

Cases involving nuchal cords (i.e., when the umbilical cord is wrapped around the baby’s neck) can also be confusing, as many coders are often quick to assign a POA indicator of Y.

Coding guidelines state that when the diagnosis of nuchal cord is documented, it’s appropriate to assign the POA indicator of Clinically Undetermined (W),” Wilson said. “The reason behind the POA indicator of W is because there is no way to determine when the cord started to wrap around the baby’s neck (in-utero or at delivery).”

Avoid assigning POA indicator Unspecifed (U)

Although coders have the option of assigning the POA indicator U (documentation is unclear), it’s wise to steer clear of using this option.

“State reporting agencies track hospital POA indicators for comparative data. POA indicators affect hospital acquired conditions (HAC) and eventually hospital reimbursement,” Wilson says.

Hospitals are not reimbursed for HACs, according to POA guidelines. (Click here to access CMS’ POA fact sheet.) “The list of HAC codes is increasing, and knowing that codes assigned with a POA indicator of Unspecified (U) are not paid will help coders realize that assigning a POA indicator of Unspecified (U) is not best practice,” says Wilson, who explains that unfortunately some providers assign an unspecified POA indicator to speed up the coding process. With the increased financial pressures placed on hospitals, coders may neglect to query the physician.

“You should be receiving state data within your hospital system as a tool to analyze your POA indicator assignments,” Wilson says. “Find out which department is receiving this vital information and share with your coders and CDI specialists.”

Editor’s note: E-mail questions to Managing Editor Doreen V. Bentley, CPC-A, at To learn more about POA indicator assignment as well as HACs, participate in HCPro’s February14 audio conference, “POAs, HACs, and HCACs for 2012: Solving Common Documentation Challenges.” Speakers Beverly Cunningham, MS, RN, and Sheila Bullock, RN, BSN, MBA, CCM, CCDS, will discuss common coding and documentation challenges associated with POA indicators, HACs, and the new Medicaid healthcare-acquired conditions (HCAC). Speakers will also cover the new HAC codes contained in the 2012 IPPS final rule.

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