It is essential for providers to capture accurate Present on Admission (POA) indicator for all diagnoses submitted on Medicare inpatient acute care claims. But is it being captured correctly? “No,” as per experts. In fact, as per then, this is one of those areas that is marred by inefficiencies, vowing to a variety of reasons.
With such a key role that these indicators play, it pays to understand what they are, why they are required and how can they be captured accurately. Keeping this in mind, we have put together everything that you need to know about POA indicators-
What is a POA Indicator?
To put it in simple words POA indicator is the patient condition that is prevalent at the time order for inpatient admission occurs. And it is essentially used to distinguish conditions present at the time of admission from those that were developed during inpatient admission.
Why is a POA Indicator Required?
With the aid of a POA indicator, the correct diagnosis related groups are assigned to inpatient claims.
What are POA Reporting Options?
Four main options are available while reporting POA indictors. This includes “Y” and “N,” which denote whether the condition was present or not respectively. The other option “U,” is employed when the documentation does not provide clear indications as to whether a particular condition is present at admission or not. And finally, the “W” option is assigned when providers are unable to clinically determine whether condition was present on admission.
How to Ensure that Accurate POA Indicators are Used?
Assigning accurate POA indicators is not the sole responsibility of a coder. In fact, according to official ICD-10-CM guidelines, the assigning of accurate indicators should involve a joint effort between the healthcare provider and the coding department. When such a combined process in place, accurate code assignment can be made when reporting diagnosis and as a result claims can be speedily processed. The best practice that coders should employ in cases where documentation is not sufficient or clear enough is to send queries to healthcare providers. Ideally, this practice of querying healthcare providers should also be followed by companies that handle claims in bulk.
Examples of when to assign “Y” or “N” POA indicator option
Assigning a “Y” for POA happens when there are documents to support the condition and in case of chronic conditions such as leukemia. It is also applied in diagnoses such as cancer which happen afterwards based on conditions such nausea and vomiting that are present at admission. However, exacerbations of COPD which happen post admission should be marked as “N” and often complications arising from pregnancy will also be assigned the same value.
Detailed explanation of when to assign “Y” and “N” POA Indicator, as reported by AAPC:
- Any condition the provider unquestionably documents as POA: Y
- A condition the provider unquestionably documents as not being POA: N
- Conditions diagnosed prior to the admission such as chronic conditions: Y
- The final diagnosis contains possible, probable, suspected, or rule-out at the time of discharge, but was not suspected on admission: N
- Conditions diagnosed during the admission that were clearly POA, but diagnosed post admission (e.g., admitted with intractable abdominal pain, nausea/vomiting and melena, final diagnosis is stomach cancer): Y
- The final diagnosis contains an impending/threatened diagnosis, but was not suspected on admission: N
- Conditions that develop during an outpatient encounter prior to a written order for inpatient admission: Y
- Scenarios where a combination code is assigned, and any part of the code was not POA (e.g. acute exacerbation of COPD, in which the exacerbation occurring post admission): N
- A newborn condition present at birth, developing in utero, or occurring during delivery (e.g. meconium aspiration): Y
- A pregnancy/obstetrical complication not POA (e.g. laceration during delivery): N
- Scenarios where a single code identifies the chronic condition only and not the acute exacerbation (e.g. acute exacerbation of chronic leukemia): Y
- A condition documented as possible, probable, suspected, or rule-out at the time of discharge, which was suspected upon admission: Y
How We Can Help You?
We are a leading medical billing and coding company in the industry that has extensive experience in dealing with POA indicators. Leveraging this experience, we can help you assign accurate POA indicators and ensure that you receive timely and accurate reimbursements. One of things that differentiates us from the rest is our usage of state of the art Computer Assisted Coding (CAC) software. We use this software to process text recorded in patient registers and also identify Present on Admission indicators to ensure that relevant codes are used in documentation. Also, our team of 500+ AAPC certified coders and superlative medical coding support provided from 8 global delivery centers needs a special mention.
