News: CDC releases 2011 ICD-10-CM/PCS coding guidelines, POA reporting

April 14, 2011

The Centers for Disease Control (CDC) in March posted new 2011 guidelines for ICD-10-CM. There are relatively few changes to conventions, general coding guidelines, and chapter specific guidelines. Adjustments are easy to spot since the CDC uses bold text for narrative changes, italics for heading changes, and underlines items that have moved within the guidelines since 2010. There are changes in chapters 5, 6, 15, 19, and 20, worthy of review; however, they have limited affect on CDI specialists.

Perhaps the most noteworthy additions are the new ICD-10-CM/PCS guidelines for reporting conditions that are present on admission (POA), included in Appendix I, as a supplement to the ICD-10-CM Official Guidelines for Coding and Reporting. The guidelines are designed to facilitate the assignment of the POA indicator for each diagnosis and external cause of injury code reported on claim forms. Some general items of interest to CDI specialists in the guidelines include the following:

Coders may use medical record documentation from any provider involved in the care and treatment of the patient to support the determination of whether a condition was POA or not. For these guidelines, a “provider” is a physician or any qualified healthcare practitioner legally accountable for establishing a patient’s diagnosis.
POA means the condition was present at the time the order for inpatient admission occurred. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery are considered POA.
Coders should assign POA indicators to principal and secondary diagnoses and the external cause of injury codes.
Providers do not have to document a condition as POA within any specified time frame.

For more on the specifics on how to assign POA indicators, review Appendix I of the guidelines. The appendix begins on p. 101.

Even though the transition is still more than a year away, it’s a good idea to at least become familiar with the guidelines now.

Editor’s Note: Information in this article was excerpted from ICD-10 Trainer Blog.

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