Present-on-Admission (POA) Coding POA Coding 06MAR2008.pdf · 31 Virginia Health Information 2008...
Transcript of Present-on-Admission (POA) Coding POA Coding 06MAR2008.pdf · 31 Virginia Health Information 2008...
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Present-on-Admission (POA) Coding
Michael Pine, MD, MBAMichael Pine and Associates, Inc
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POA and Coding Guidelines (1)
• Unless otherwise specified, a POA modifier must be assigned to each principal and secondary diagnosis
• POA does not apply to conditions that are not coded and reported based on current coding guidelines
• A diagnosis is POA if it is present at the time the order for inpatient admission occurs
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POA and Coding Guidelines (2)
• Current coding guidelines are not affected by the POA modifier
• POA coding must be supported by medical record documentation by a qualified healthcare practitioner
• Issues of inconsistent, missing, conflicting or unclear documentation must be resolved by a qualified healthcare practitioner
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Valid POA Codes• Y = present at time of order to admit
• N = not present at time of order to admit
• U = insufficient documentation to determine if Y or N
• W = provider unable to determine if Y or N
• blank = diagnosis exempt from POA reporting
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Assigning POA Indicators (1)• Conditions on “Exempt from Reporting” list
• Conditions explicitly documented Y or N
• Conditions diagnosed prior to inpatient admission (Y)
• Conditions that develop during outpatient encounter prior to inpatient admission (Y)
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Assigning POA Indicators (2)• Acute conditions present on admission (Y)
• Conditions diagnosed with combination codes when all parts of code are present on admission (Y)
• Chronic conditions regardless of when diagnosed (Y)
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Assigning POA Indicators (3)
• Conditions diagnosed during admission but clearly present prior to admission (Y)
• Infection codes with causal organism when infection or signs of infection present on admission but organism not known until after admission (Y)
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Assigning POA Indicators (4)• Comparative or contrasting diagnoses, each
present or suspected on admission (Y for each)
• Acute conditions not present on admission (N)
• Chronic condition with acute exacerbation during admission (N for combination codes with acute component; Y for exclusively chronic codes)
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Assigning POA Indicators (5)• Conditions documented on discharge as possible,
probable, suspected, or rule-out (diagnosis suspected on admission [Y] or, if diagnosis not suspected on admission, associated symptoms or clinical findings present on admission [Y], otherwise [N])
• Conditions documented on discharge as impending or threatened (if associated symptoms or clinical findings present on admission [Y], otherwise [N])
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Assigning POA Indicators (6)• Documentation does not indicate whether
condition was present on admission (attempt to clarify)
• Documentation that qualified practitioner cannot determine whether condition was or was not present on admission (W)
• Coder unable to obtain information about whether condition was present on admission (U)
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Assigning POA Indicators (7)
• For pregnant patients, POA assignment is determined by relation of pregnancy-related conditions or complications to admission and is not affected by whether or not the patient delivers (if present on admission [Y], otherwise [N])
• If obstetrical code includes more than one diagnosis and any included diagnosis not present on admission (N)
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Assigning POA Indicators (8)• For an obstetrical code that include non-
diagnostic information (eg, conversion of breech to cephalic presentation), ignore timing of non-diagnostic information (all diagnoses present on admission but non-diagnostic information relates to post-admission events [Y])
• For newborns, in utero conditions are present on admission (ie, the time of birth) (Y)
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Assigning POA Indicators (9)• For newborn, complications that occur during
delivery (Y)
• All congenital conditions and anomalies (Y)
• POA for E codes are based on the relation of the time of injury to the time of admission (when injury is prior to admission [Y], otherwise [N])
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POA – Example #1• A patient is admitted for a diagnostic work-up of
severe cough and difficulty breathing
• The final diagnosis is malignant neoplasm of the middle lobe of the lung
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POA Code for Example #1
• A patient is admitted for a diagnostic work-up of severe cough and difficulty breathing
• The final diagnosis is malignant neoplasm of the middle lobe of the lung
• ICD-9-CM = 162.4; POA = Y
• Although the malignant neoplasm is not diagnosed until after admission, it is clearly present on admission
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POA – Example #2• During the recovery period after outpatient
surgery, a patient develops atrial fibrillation and subsequently is admitted to the hospital as an inpatient
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POA Code for Example #2• During the recovery period after outpatient
surgery, a patient develops atrial fibrillation and subsequently is admitted to the hospital as an inpatient
• ICD-9-CM = 427.31; POA = Y
• Atrial fibrillation develops prior to a written order for inpatient admission
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POA – Example #3
• While being treated in Observation, a patient falls out of bed and breaks a hip
• The patient subsequently is admitted to the hospital as an inpatient with a closed transcervical fracture of the base of the neck of the femur
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POA Code for Example #3• While being treated in Observation, a patient falls out of
bed and breaks a hip
• The patient subsequently is admitted to the hospital as an inpatient with a closed transcervical fracture of the base of the neck of the femur
• ICD-9-CM = 820.03; POA = Y
• The hip fracture develops prior to a written order for inpatient admission
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POA – Example #4
• A patient with known chronic systolic heart failureis admitted to the hospital after developing decompensated heart failure
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POA Code for Example #4• A patient with known chronic systolic heart failure
is admitted to the hospital after developing decompensated heart failure
• ICD-9-CM = 428.23; POA = Y
• Both elements of the combination code for acute on chronic systolic heart failure occur prior to admission
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POA – Example #5• A patient develops fever after inpatient surgery
and is treated aggressively
• The physician’s final diagnosis is “possible postoperative infection”
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POA Code for Example #5
• A patient develops fever after inpatient surgery and is treated aggressively
• The physician’s final diagnosis is “possible postoperative infection”
• ICD-9-CM = 998.51; POA = N
• Symptom or finding on which possible, probable, suspected, or rule-out diagnosis is based is not present on admission
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POA – Example #6• A patient develops a pulmonary embolism after
coronary artery bypass surgery
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POA Code for Example #6• A patient develops a pulmonary embolism after
coronary artery bypass surgery
• ICD-9-CM = 415.11; POA = N
• This acute condition is not present on admission
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POA – Example #7
• A patient who has a prior subendocardial myocardial infarction is admitted with an impending acute myocardial infarction
• The physician’s final diagnosis is “acute subendocardial myocardial infarction”
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POA Code for Example #7• A patient who has a prior subendocardial
myocardial infarction is admitted with an impending acute myocardial infarction
• The physician’s final diagnosis is “acute subendocardial myocardial infarction”
• ICD-9-CM = 410.71; POA = Y
• This acute condition is present on admission
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POA – Example #8
• A patient with uncomplicated type II diabetes mellitus develops uncontrolled diabetes on day 3 of a hospitalization
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POA Code for Example #8
• A patient with uncomplicated type II diabetes mellitus develops uncontrolled diabetes on day 3 of a hospitalization
• ICD-9-CM = 250.02; POA = N
• The acute portion of this combination code is not present on admission
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POA – Example #9• A patient admitted with pneumonia and high fever
rapidly deteriorates and becomes septic
• Discharge diagnoses include sepsis and pneumonia with no specified organism, and it is unclear from the medical record precisely when the sepsis developed
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POA Code for Example #9 (step 1)
• A patient admitted with pneumonia and high fever rapidly deteriorates and becomes septic
• Discharge diagnoses include sepsis and pneumonia with no specified organism, and it is unclear from the medical record precisely when the sepsis developed
• Query the physician to determine organism and whether sepsis was present on admission
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POA Code for Example #9 (step 2)
• A patient admitted with pneumonia and high fever rapidly deteriorates and becomes septic
• Discharge diagnoses include sepsis and pneumonia
• Physician confirms that the organism is unknown and that she is unsure whether sepsis was present on admission
• ICD-9-CM = 038.9; POA = W
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POA – Example #10• A patient is admitted for elective repair of an
abdominal aortic aneurysm; however, the aneurysm ruptures prior to surgery but after hospital admission
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POA Code for Example #10• A patient is admitted for elective repair of an
abdominal aortic aneurysm; however, the aneurysm ruptures prior to surgery but after hospital admission
• ICD-9-CM = 441.3; POA = N
• The acute portion of this combination code does not occur until after admission
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POA – Example #11• A patient is admitted with viral hepatitis B and
progresses to hepatic coma after admission
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POA Code for Example #11• A patient admitted with viral hepatitis B and
progresses to hepatic coma after admission
• ICD-9-CM = 070.2; POA = N
• The acute portion of this combination code does not occur until after admission
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POA – Example #12
• A patient with a history of varicose veins and ulceration accidentally injures his leg while hospitalized and the ulcerated area bleeds profusely
• The physician’s final diagnosis is “varicose veins with ulcer and hemorrhage”
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POA Code for Example #12• A patient with a history of varicose veins and ulceration
accidentally injures his leg while hospitalized and the ulcerated area bleeds profusely
• The physician’s final diagnosis is “varicose veins with ulcer and hemorrhage”
• ICD-9-CM = 454.0; POA = Y
• The hemorrhage occurs after admission, but it is not included in the ICD-9-CM code
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POA – Example #13 (a trick question)• A female patient has a normal delivery in the
hospital
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POA Code for Example #13• A female patient has a normal delivery in the
hospital
• ICD-9-CM = 650; POA = (blank)
• Normal delivery is on the “exempt from reporting” list
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POA – Example #14
• A patient in late pregnancy is admitted with excessive vomiting
• During hospitalization she goes into premature labor
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POA Code for Example #14• A patient in late pregnancy is admitted with
excessive vomiting
• During hospitalization she goes into premature labor
• ICD-9-CM = 643.2; POA = YICD-9-CM = 644.2; POA = N
• Excessive vomiting is present on admissionPremature labor is not present on admission
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POA – Example #15
• After normal delivery of a hospitalized patient, a breast abscess is noted when she attempts to breast feed
• The physician is unable to determine whether the abscess was present on admission
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POA Code for Example #15
• After normal delivery of a hospitalized patient, a breast abscess is noted when she attempts to breast feed
• The physician is unable to determine whether the abscess was present on admission
• ICD-9-CM = 611.0; POA = W
• Healthcare provider is unable to determine when breast abscess occurred
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POA – Example #16
• After patient is admitted in active labor
• After 12 hours of labor, fetal distress is noted and a Cesarean section is performed
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POA Code for Example #16• After patient is admitted in active labor
• After 12 hours of labor, fetal distress is noted and a Cesarean section is performed
• ICD-9-CM = 656.8; POA = N
• Fetal distress is not present on admission
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POA – Example #17• A newborn developed diarrhea that is thought to
be due to the hospital baby formula
![Page 48: Present-on-Admission (POA) Coding POA Coding 06MAR2008.pdf · 31 Virginia Health Information 2008 line POA Code for Example #9 (step 1) • A patient admitted with pneumonia and high](https://reader030.fdocuments.net/reader030/viewer/2022021510/5b148e8d7f8b9a207c8dc331/html5/thumbnails/48.jpg)
48lineVirginia Health Information 2008
POA Code for Example #17• A newborn developed diarrhea that is thought to
be due to the hospital baby formula
• ICD-9-CM = 787.91; POA = N
• Diarrhea develops after the newborn’s admission (ie, the time of birth)
![Page 49: Present-on-Admission (POA) Coding POA Coding 06MAR2008.pdf · 31 Virginia Health Information 2008 line POA Code for Example #9 (step 1) • A patient admitted with pneumonia and high](https://reader030.fdocuments.net/reader030/viewer/2022021510/5b148e8d7f8b9a207c8dc331/html5/thumbnails/49.jpg)
49lineVirginia Health Information 2008
POA – Example #18• A single live infant is delivered in the hospital by
Cesarean section
• The physician lists fetal bradycardia during laborin the final diagnoses in the newborn record
![Page 50: Present-on-Admission (POA) Coding POA Coding 06MAR2008.pdf · 31 Virginia Health Information 2008 line POA Code for Example #9 (step 1) • A patient admitted with pneumonia and high](https://reader030.fdocuments.net/reader030/viewer/2022021510/5b148e8d7f8b9a207c8dc331/html5/thumbnails/50.jpg)
50lineVirginia Health Information 2008
POA Code for Example #18• A single live infant is delivered in the hospital by
Cesarean section
• The physician lists fetal bradycardia during laborin the final diagnoses in the newborn record
• ICD-9-CM = 653.82; POA = Y
• Bradycardia develops prior to the newborn’s admission (ie, the time of birth)