Present on Admission (POA) Indicators and Reporting Flashcards

When querying a physician to clarify POA status, what must the query include to remain compliant?

Answer: Clinical indicators from the medical record that prompted the need for clarification

A compliant query must be non-leading and based on clinical indicators found in the documentation, without suggesting a preferred answer or referencing reimbursement impact.

A patient is transferred from a skilled nursing facility with a Stage 2 pressure ulcer on the sacrum, documented as present prior to transfer. What POA indicator applies?

Answer: Y — present at the time of inpatient admission

Since the pressure ulcer was documented as present before the inpatient admission order, POA indicator 'Y' is assigned.

Which of the following best defines 'Present on Admission' for ICD-10-CM coding purposes?

Answer: A condition present at the time of the order for inpatient admission

POA is officially defined as a condition present at the time of the order for inpatient admission, including conditions that developed during an outpatient encounter resulting in the admission.

A patient with documented atrial fibrillation is admitted for elective cardioversion. What POA indicator applies to the atrial fibrillation?

Answer: Y — present at the time of the inpatient admission order

Atrial fibrillation was clearly the reason for admission and was present before the admission order was placed, making POA indicator 'Y' correct.

Which organization publishes the official POA indicator reporting guidelines used by inpatient coders in the United States?

Answer: The Centers for Medicare & Medicaid Services (CMS)

CMS publishes the official POA reporting guidelines as part of the inpatient prospective payment system final rule and related transmittals.

A patient develops a deep vein thrombosis (DVT) on post-operative day 4, confirmed not to be present at admission. What is the most appropriate coding action?

Answer: Assign POA indicator N and code the DVT, noting the potential HAC impact on reimbursement

Accurate coding requires assigning POA indicator 'N' and reporting the DVT; omitting a diagnosis or manipulating POA status for financial reasons constitutes fraudulent billing.

Which condition would most appropriately receive a POA indicator of 'W'?

Answer: A pressure ulcer whose depth and staging could not be clinically determined at the time of admission

POA indicator 'W' is appropriate when the clinician cannot clinically determine if a condition was present at admission — such as a pressure ulcer that cannot be fully assessed or staged on arrival.