Submitted by
Cheryl A. Friedman, RN, MHA
System Vice President of Care Management and Documentation Integrity

INTRODUCTION: Although the abbreviation POA does stand for Power of Attorney the abbreviation POA in the world of Documentation Integrity and Coding denotes something different…namely what is PRESENT ON ADMISSION … This intriguing article helps answers your questions.

What is Present on Admission? There is an official definition!
International Classification of Diseases, Clinical Modification (ICD-10 CM) Official Guidelines for Coding and Reporting (PDF), issued by the National Center for Health Statistics and the Centers for Medicare and Medicaid Services (CMS), defines Present on Admission (POA) as:

  • Present at the time the order for inpatient admission occurs.
  • Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.”
  • Conditions diagnosed during the admission that were clearly present on admission but not diagnosed or confirmed until after admission
  • A final diagnosis that contains a possible, probable, suspected, or rule out diagnosis and this diagnosis was based on symptoms or clinical findings suspected at the time of the inpatient admission.
  • Any external cause code representing an external cause of morbidity/severity that occurred prior to admission. For example: “Patient fell out of bed at home”

CMS now requires hospitals to enter POA indicators on all inpatient acute-care hospital claims. This requirement is intended to identify certain diagnoses that are:

  • High in cost, high in volume, or both.
  • Elevates patients to a higher paying diagnostic related group (DRG) when present as a secondary diagnosis.
  • Reasonably preventable through application of evidence-based medicine.

How does this impact Catholic Health?
For discharges after October 1, 2008 hospitals may not receive appropriate payment for cases in which one of the selected conditions was not present on admission (POA)… penalizing hospitals when a certain diagnosis is present on discharge but not on admission. For example and to name a few:

  • Catheter-associated urinary tract infections
  • Pressure ulcers
  • Hospital falls
  • Vascular catheter-associated infections
  • Surgical site infections
  • Serious preventable events, such as objects left in surgery, air embolism, or blood incompatibility

What do I need to do as a provider?

Clear documentation is critical. Key documentation points include:

  • Completely document all conditions that are clinically POA and conditions that manifest after admission but can be traced back to the presenting signs and symptoms.
  • Link diagnoses with symptoms. For example, a patient is admitted with low blood pressure. On day two, the physician identifies that the low blood pressure is due to septic shock. If the physician does not link the two, it will appear as though the septic shock occurred after the patient was admitted.
  • Document any ruled out, possible, and suspected conditions POA or ruled out conditions that developed during the hospital stay.
  • Clearly identify chronic conditions with acute exacerbations.
  • Document infections POA and the causal organism, if known.
  • Document the cause of any injury or poisoning and include where it occurred.
  • LASTLY
    • A clear and precise patient history and physical examination are critical to compliant coding.
    • It’s critical that when providers conduct a patient history and physical examination that they relate the signs and symptoms present on admission to the actual condition causing the problem and as the reason for admission to the hospital
    • For every diagnosis code that coders assign from the inpatient record, they assign an indicator to denote whether that condition was POA. In addition to your H and P, coders and the documentation specialists review your documentation in progress notes, consultant notes, anesthesia notes, and other medical record documentation to determine POA status.
    • When possible, please respond to all of your CDEI and HIM queries.
    • Please know that your CDEI and Coding teams are ALWAYS available to assist, educate and answer any/all of your questions.
  • KEY TAKE AWAY: WE CAN’T HELP GET YOUR POWER OF ATTORNEY (POA) BUT WE CAN HELP WITH YOUR PRESENT ON ADMISSION (POA) DIAGNOSIS!!!!!