CCDS POA and Hospital-Acquired Conditions (HACs) 2

Question 1

Which POA indicator is assigned when documentation is insufficient to determine if the condition was present at the time of inpatient admission?

Accepted Answer

U - Documentation is insufficient to determine POA status

Answer

Y - Yes, present at time of admission

Answer

N - Not present at time of admission

Answer

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?

Accepted Answer

Central line-associated bloodstream infection (CLABSI)

Answer

Community-acquired pneumonia

Answer

Congestive heart failure exacerbation

Answer

Diabetic ketoacidosis

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?

Accepted Answer

Y - Present at admission, since the nursing note documents it at time of triage

Answer

N - Not present at admission, since the physician did not document it

Answer

U - Undetermined, since only nursing documentation supports it

Answer

W - Clinically undeterminable

Question 4

Which diagnosis has a POA indicator exempt status and does not require POA reporting?

Accepted Answer

External cause codes (V, W, X, Y codes) for injuries

Answer

Deep vein thrombosis (DVT)

Answer

Hospital-acquired pressure ulcers

Answer

Ventilator-associated pneumonia

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?

Accepted Answer

Code stage IV with POA=Y since the ulcer was present at admission regardless of progression

Answer

Code stage III with POA=Y and do not code the progression

Answer

Code stage III with POA=Y and stage IV with POA=N as a separate diagnosis

Answer

Code only stage IV with POA=N since that is the final documented stage

Question 6

Which of the following is TRUE regarding the POA indicator 'W' (clinically undeterminable)?

Accepted Answer

It applies when the provider cannot clinically determine whether a condition was present at admission despite thorough review

Answer

It is used interchangeably with 'U' when documentation is missing

Answer

It must be assigned for all diagnoses in the obstetrics code range

Answer

It is only used for HAC-designated conditions