Health Information Management

Five tips to help capture the present-on-admission indicator

HIM-HIPAA Insider, March 13, 2007

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If you're wondering how your coders are going to capture the present-on-admission (POA) indicator once your state requires it, you don't have to look far beyond the hospitals in California or New York--two states that have been reporting it on a state level since the mid-1990s.

Although reporting the POA initially meant an increased burden for coders and providers, it was the California hospitals themselves that were the impetus behind the state's 1996 adoption of the indicator as part of its patient discharge data program, says Candace Diamond, manager of the patient data section of the healthcare information division of the California Office of Statewide Health Planning and Development (OSHPD) in Sacramento, CA.

Consider these tips when implementing the POA requirements at your hospital:

#1: Determine your state's implementation deadline. This will vary from state to state. Some states started on January 1. "We're concerned that if you're in a state with an early deadline, you're not getting the message," says Nelly Leon-Chisen, RHIA, director of coding and classification for the American Hospital Association in Chicago. Leon-Chisen alludes to the fact that if the implementation date is early, certain states may not even know that they need to report it, let alone how.

#2: Distinguish between national and state requirements. These may be slightly different, Diamond points out. For example, California only requires providers to report POA based on three indicators (yes, no, or uncertain), instead of four (yes, no, unknown, or clinically undetermined) and does not require providers to report it for E codes or primary diagnoses. Your state's requirements may also vary from those on the national level.

#3: Build an interdisciplinary team. This team can help alert administration, physicians, and finance of the changes, as well as approach documentation improvement proactively and define a more refined query system, if necessary.

#4: Apply the POA guidelines to a sample set of records. "Try to identify problems with the documentation and alert physicians that you're going to ask for their cooperation and that they may receive an additional query," says Leon-Chisen.

#5: Educate physicians. Work with physicians and explain to them why you need this information. You might need to present examples of good vs. poor documentation. Or, you could focus on the physicians who need the most help. "Maybe you don't have to work with everyone," Leon-Chisen adds.

Editor's note: Stay tuned for next week's HIM Connection to learn five more tips. The above article was adapted from For more information or to order, call 877/727-1728 or go to

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