CCDS POA and Hospital-Acquired Conditions (HACs) 2 — Questions and Answers
Question 1: Which POA indicator is assigned when documentation is insufficient to determine if the condition was present at the time of inpatient admission?
- Y - Yes, present at time of admission
- N - Not present at time of admission
- U - Documentation is insufficient to determine POA status (Correct answer)
- W - Clinically undeterminable
Correct answer: U - Documentation is insufficient to determine POA status
The 'U' indicator is assigned when the medical record documentation does not have sufficient information to determine whether the condition was present at admission.
POA indicators are required for all principal and secondary diagnoses on Medicare inpatient claims. The four valid indicators are Y (present at time of inpatient admission), N (not present at time of inpatient admission), U (documentation is insufficient), and W (clinically undeterminable).
Question 2: Under the HAC payment adjustment, which of the following conditions would trigger a payment reduction if NOT documented as present on admission?
- Community-acquired pneumonia
- Central line-associated bloodstream infection (CLABSI) (Correct answer)
- Congestive heart failure exacerbation
- Diabetic ketoacidosis
Correct answer: Central line-associated bloodstream infection (CLABSI)
CLABSI is one of CMS's designated HACs. When CLABSI develops during the hospitalization and is not documented as POA=Y, CMS will not pay the additional costs associated with treating that complication.
CMS's HAC payment adjustment program covers multiple categories of conditions, including CLABSI, CAUTI, surgical site infections, falls with fractures, and others. When any of these conditions are coded without POA=Y, the MS-DRG is reassigned to the lower-complexity version as if the HAC were not present.
Question 3: A patient is admitted through the ED with a stage II pressure ulcer documented in the triage nursing note. The admitting physician's H&P does not mention the pressure ulcer. What is the correct POA indicator?
- N - Not present at admission, since the physician did not document it
- Y - Present at admission, since the nursing note documents it at time of triage (Correct answer)
- U - Undetermined, since only nursing documentation supports it
- W - Clinically undeterminable
Correct answer: Y - Present at admission, since the nursing note documents it at time of triage
A condition documented in any part of the medical record at the time of admission including nursing assessments during triage can be assigned POA=Y.
ICD-10-CM POA guidelines state that a condition is considered POA when it is present at the time of the order for inpatient admission. This includes conditions documented in the ED, observation notes, or nursing assessments prior to or at the point of formal inpatient admission.
Question 4: Which diagnosis has a POA indicator exempt status and does not require POA reporting?
- Deep vein thrombosis (DVT)
- External cause codes (V, W, X, Y codes) for injuries (Correct answer)
- Hospital-acquired pressure ulcers
- Ventilator-associated pneumonia
Correct answer: External cause codes (V, W, X, Y codes) for injuries
External cause codes (ICD-10-CM V, W, X, Y codes) are exempt from POA reporting requirements. These codes describe circumstances of injury such as falls or motor vehicle accidents.
CMS maintains a list of codes that are exempt from POA reporting. External cause codes (V00-Y99) are universally exempt because they describe the circumstances of an injury or event rather than a clinical diagnosis, and the concept of 'present at admission' is not applicable.
Question 5: A patient with documented stage III pressure ulcer on the coccyx at admission progresses to stage IV during the hospitalization. How should the POA and final pressure ulcer stage be coded?
- Code stage III with POA=Y and do not code the progression
- Code stage IV with POA=Y since the ulcer was present at admission regardless of progression (Correct answer)
- Code stage III with POA=Y and stage IV with POA=N as a separate diagnosis
- Code only stage IV with POA=N since that is the final documented stage
Correct answer: Code stage IV with POA=Y since the ulcer was present at admission regardless of progression
When a pressure ulcer is present on admission at a lower stage and worsens during the hospitalization, the highest stage documented during the stay is coded with POA=Y.
ICD-10-CM guidelines specify that for pressure ulcers that are present on admission at one stage and progress during the hospitalization, the highest stage documented during the stay should be coded. The POA indicator reflects whether the original ulcer was present, not whether the final stage was present.
Question 6: Which of the following is TRUE regarding the POA indicator 'W' (clinically undeterminable)?
- It is used interchangeably with 'U' when documentation is missing
- It applies when the provider cannot clinically determine whether a condition was present at admission despite thorough review (Correct answer)
- It must be assigned for all diagnoses in the obstetrics code range
- It is only used for HAC-designated conditions
Correct answer: It applies when the provider cannot clinically determine whether a condition was present at admission despite thorough review
The 'W' indicator is used when the clinical provider determines that it is not possible to clinically determine whether the condition was present at the time of admission, despite thorough clinical review.
'W' (Clinically undeterminable) and 'U' (Documentation insufficient to determine) are distinct POA indicators. 'W' is a clinical determination where the physician has reviewed the record and genuinely cannot determine whether the condition was present at admission. 'U' is a documentation problem where the record lacks sufficient information.
CCDS POA and Hospital-Acquired Conditions (HACs) 2
Which POA indicator is assigned when documentation is insufficient to determine if the condition was present at the time of inpatient admission?