Health Information Management

Tip of the week: Prepare now for the present-on-admission indicator

HIM-HIPAA Insider, June 26, 2007

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Educate staff now on how to capture the present-on-admission (POA) indicator. Take the following steps:

  • Ensure that you have updated medical protocols for each of the 13 conditions on the proposed POA list. If your facility doesn't already do this, form a committee that will discuss how to avoid certain circumstances and then develop a protocol around those ideas.
  • Take a closer look at documentation. Encourage ER physicians, nurses, and other providers to document all conditions that were present at the time of admission. Coders can typically look for this information in the history and physical or nursing notes.
  • Download a copy of the POA guidelines on the Centers for Disease Control and Prevention Web site. Scroll to p. 91 (Appendix I), which is where the guidelines begin. Pay close attention to grey areas, such as when you can report a combination code as being POA. The guidelines state that both the chronic and acute conditions must be POA to report it with a yes. Also provide a copy of the guidelines to physicians.
  • Read up on other resources. Refer to the following new resources that the Centers for Medicare & Medicaid Services has provided:
    -Transmittal 1240
    -Medlearn Matters article 5499
  • Provide up-front educational sessions for both coders and physicians. This will help to ensure that coders report the POA consistently within your organization.
  • Contact your coding vendor. Determine whether your vendor plans to incorporate any POA tools into the software that will prompt coders to report the indicator.

For more information, click here. Subscribers to Medical Records Briefing can view this article in the July issue.

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