Health Information Management

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

HIM-HIPAA Insider, March 20, 2007

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Last week, HIM Connection brought you five tips to help your coders capture the present-on-admission (POA) indicator once your state requires it.

You might also want to consider providing physicians with a clinical scenario and then show them what coders must glean related to the POA from the information they provide, says Gloryanne Bryant, BS, RHIA, CCS, director of system-wide coding/HIM compliance for Catholic Healthcare West in San Francisco. "Tell them, 'Here's a clinical scenario, and here's what we have to answer. How would you interpret this?' "she says. "And then, compare that with what the coder would assign."

(Note: Refer to the ICD-9-CM Official Guidelines for Coding and Reporting for a helpful list of scenarios.)

Consider these tips, in addition to last week's tips, when implementing the POA requirements at your hospital:

  • Tip #6: Seek internal resources. Physicians could serve as an excellent resource to help coders understand what types of diagnoses they typically see POA, 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. Infection control specialists might also already be tracking this type of information, she adds. If your hospital has an outpatient clinic that acts as a follow-up to inpatient care, it might be able to help track what conditions and diseases tend to be chronic.
  • Tip #7: Perform an impact analysis. Start with infections, says Caroline Piselli of 3M Health Information Systems in Wallingford, CT. "Ensure that all infection-prevention practices are implemented," says Piselli. Ask the following questions:
    • How often do infections occur?
    • Do they occur before, during, or after surgery?
    • Can the facility tighten up some of its clinical practices to minimize the number of patients who develop an infection?
  • Tip #8: Contact colleagues in states that are already collecting the POA indicator. Ask them how they're doing it and what kinds of problems, if any, they encountered, says Bryant.
  • Tip #9: Contact your state's health information management association. This could provide you with a wealth of information and alert you to educational sessions and publications
  • Tip #10: Have a discussion with vendors. Ensure that your abstract vendor will be able to crosswalk data appropriately to the UB-94.

Editor's note: The above article was adapted from For more information or to order, call 877/727-1728 or go to

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