Present on Admission (POA) indicators are used in inpatient medical coding to indicate whether a condition was present at the time of admission to the hospital. POA indicators are used to classify conditions as either “present on admission” or “not present on admission”. The use of POA indicators is important because it affects hospital payment and quality metrics.
The Centers for Medicare and Medicaid Services (CMS) introduced POA indicators in 2007 as part of their effort to reduce hospital-acquired conditions (HACs) and improve the accuracy of hospital billing. By identifying conditions that were present on admission, CMS hoped to reduce the financial burden on hospitals for conditions that were acquired during a patient’s stay.
There are several POA indicator codes that can be used to indicate the status of a condition at the time of admission. These codes include:
- Y (present on admission)
- N (not present on admission)
- U (documentation insufficient to determine whether condition was present on admission)
- W (clinically undetermined; provider unable to clinically determine whether condition was present on admission)
The Y code is used when the condition was present on admission, while the N code is used when the condition was not present on admission. The U code is used when the documentation is insufficient to determine whether the condition was present on admission, and the W code is used when the provider is unable to clinically determine whether the condition was present on admission.
POA indicators are used in conjunction with diagnosis codes to determine the payment and quality metrics for hospital stays. The payment and quality metrics are affected by the POA status of the condition. For example, if a patient is admitted with a condition that is not present on admission, the hospital may not be reimbursed for the additional cost associated with treating the condition. Additionally, the hospital’s quality metrics may be negatively impacted by the presence of hospital-acquired conditions.
POA indicators are also used to track the incidence of HACs. Hospitals are required to report certain HACs to the CMS, and the use of POA indicators helps to identify which conditions were present on admission and which were acquired during the patient’s stay.
The use of POA indicators requires accurate documentation by the healthcare provider. Providers must document the status of each condition at the time of admission to ensure that the correct POA indicator is assigned. This documentation includes a detailed history and physical examination, as well as any relevant diagnostic tests or procedures.
POA indicators are an important part of inpatient medical coding and billing. By accurately identifying the status of a condition at the time of admission, hospitals can ensure that they are reimbursed for the appropriate services and that their quality metrics accurately reflect the care provided. Additionally, the use of POA indicators helps to reduce the incidence of hospital-acquired conditions and improve the overall quality of care provided to patients.