Why Collect?

POA will add precision to ICD-9-CM coding in administrative data because it would distinguishbetween pre-existing conditions and complications

POA will increase efficiency of hospital assurance activities by reducing the number of false positives that hospitals with patient safety programs need to investigate further

POA will improve accuracy of safety and quality-of-care measures, including AHRQ Patient Safety Indicators (PSIs), Lezzoni and Colleagues Complications Screening Program (CSP), and the new 3M potentially Preventable Complications (PPCs)

POA will increase the validity of hospitals report cards

Improve accuracy of results in mortality risk assessment and outcomes research

Improve design and fairness of pay-for-performance programs

The California Office of Statewide Health Planning and Development (OSHPD) implemented POA in 1996

The New York Department of Health (NYSDOH), through it bureau of Statewide Planning and Research Cooperative System (SPARCS), implemented POA data collection in 1994

Who is required to report ?

All inpatient admission to general acute care hospital or other facilities that are subject to a law or regulation mandating collection of present on admission information must report

Effective October 1, 2007, Medicare providers must submit a POA Indicator for every diagnosis on their inpatient acute care hospital claims.

These hospitals are exempt from this requirement: Maryland waiver hospitals, long term care hospitals, cancer hospitals, psychiatric hospitals, inpatient rehabilitation facilities, and children’s inpatient facilities.

Reporting Guidelines:

POA is defined 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

POA is assigned to principal and secondary diagnoses and the external cause of injury codes

If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported

Issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider

Assign “Y” for any condition the provider explicitly documents as being present on admission

Assign “Y” for any condition the provider explicitly documents as not present at the time of admission

Assign “Y” for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred

Assign “Y” for any condition that develops during an outpatient encounter prior to a written order for inpatient admission

Assign “Y” for chronic conditions, even though the condition may not be diagnosed until after admission

Obstetrical conditions:

Whether or not the patient delivers during the current hospitalization does not affect assignment of the POA indicator. The determining factor for POA assignment is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission or not.

If the pregnancy complication or obstetrical condition was present on admission assign “Y”

If the pregnancy complication or obstetrical condition was not present on admission (e.g. 2nd degree laceration during delivery, postpartum hemorrhage occurred during current hospitalization, fetal distress develops after admission), assign “N”

Perinatal condition

Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered present at admission and should be assigned “Y”. This includes conditions that occur during delivery (e.g. injury during deliver, meconium aspiration, exposure to strep B in the vaginal canal)

Congenital conditions and anomalies

Assign “Y” for congenital conditions and anomalies. Congenital conditions are always considered present on admission.

E-Codes

Assign “Y” for E code representing an external cause of injury or poisoning that occurred prior to inpatient admission (fall out of bed at home, fall out of bed in emergency room prior to admission)

Assign “N” for any E code representing an external cause of injury or poisoning that occurred during inpatient hospitalization (e.g. patient fell out of hospital bed during the hospital stay, patient experienced an adverse reaction to a medication administered after inpatient admission)

Conditions on the “Exempt from Reporting” list

Leave the “present on admission” field blank if the condition is on the list of ICD-9-CM codes for which this field is not applicable. This is the only circumstance in which the field may be left blank

Reporting Options/Definitions

Y=present at the time of inpatient admission

N=not present at the time of inpatient admission

U=documentation is insufficient to determine if condition is present on admission

W=provider is unable to clinically determine whether conditions was present on admission or not

Remember: That medical record documentation from any provider (a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis) involved in the patient’s care and treatment may be used to support the determination of whether a condition was present on admission or not.

For additional information or to obtain a copy of the official reporting guidelines.  Follow the links below

http://www.cms.hhs.gov/Transmittals/downloads/R1240CP.pdf on the CMS website

MLN Matters number: 5499
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm (official reporting guidelines)