Present on Admission (POA)
It is very important for a medical coder to be able to differentiate whether a condition was present on a patients admittance to the hospital, or whether it was acquried while in the hospital. The present on admission (POA) indicator only applies to diagnosis of inpateint admissions to the acute care hospital setting, and used for pubic health reporting. Hospital aquired diseases are heavily regulated in effort to iprove the quality of care delivered.
The POA Indicator Reporting provision applies only to IPPS hospitals.The following hospitals are EXEMPT from the POA indicator requirement:
❖ Critical Access Hospitals (CAHs),
❖ Long-Term Care Hospitals (LTCHs),
❖ Maryland Waiver Hospitals,
❖ Cancer Hospitals,
❖ Children’s Inpatient Facilities,
❖ Rural Health Clinics,
❖ Federally Qualified Health Centers (FQHCs),
❖ Religious Non-Medical Health Care Institutions,
❖ Inpatient Psychiatric Hospitals,
❖ Inpatient Rehabilitation Facilities (IRFs), and
❖ Veterans Administration/Department of
❖ Defense Hospitals.
General Reporting Requirements
❖ The POA indicator is required for all claims involving Medicare inpatient admissions to general IPPS acute care hospitals or other facilities that are subject to a law or
regulation mandating collection of POA indicator information.
❖ 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 POA.
❖ The POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the ICD-9-CM Official Guidelines for Coding and Reporting). For the
Official Guidelines, please visit http://www.cdc.gov/nchs/icd/icd9cm.htm on the Internet.
❖ Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider.
❖ If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current Official Guidelines, then the POA indicator would
not be reported.
❖ CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”
Information was taken from the department of Health and Human Services Centers for Medicare and Medicain Services "Present on Admission (POA) Indiicator Reporting by Acute Inpatient Prospective Payment System (IPPS) Hospitals.
The POA Indicator Reporting provision applies only to IPPS hospitals.The following hospitals are EXEMPT from the POA indicator requirement:
❖ Critical Access Hospitals (CAHs),
❖ Long-Term Care Hospitals (LTCHs),
❖ Maryland Waiver Hospitals,
❖ Cancer Hospitals,
❖ Children’s Inpatient Facilities,
❖ Rural Health Clinics,
❖ Federally Qualified Health Centers (FQHCs),
❖ Religious Non-Medical Health Care Institutions,
❖ Inpatient Psychiatric Hospitals,
❖ Inpatient Rehabilitation Facilities (IRFs), and
❖ Veterans Administration/Department of
❖ Defense Hospitals.
General Reporting Requirements
❖ The POA indicator is required for all claims involving Medicare inpatient admissions to general IPPS acute care hospitals or other facilities that are subject to a law or
regulation mandating collection of POA indicator information.
❖ 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 POA.
❖ The POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the ICD-9-CM Official Guidelines for Coding and Reporting). For the
Official Guidelines, please visit http://www.cdc.gov/nchs/icd/icd9cm.htm on the Internet.
❖ Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider.
❖ If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current Official Guidelines, then the POA indicator would
not be reported.
❖ CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”
Information was taken from the department of Health and Human Services Centers for Medicare and Medicain Services "Present on Admission (POA) Indiicator Reporting by Acute Inpatient Prospective Payment System (IPPS) Hospitals.