Q&A: Why query for POA status?

Q: What would be the purpose of coding for a present on admission (POA) status of things like a urinary tract infection (UTI)/pyelonephritis, encephalopathy, chest pain, abdominal pain, etc.?

Also, does the provider have to state these conditions were POA or can the principal diagnosis be implied in some situations when the treatment is geared toward a particular diagnosis or the diagnostics are focused on one thing in particular?

A: One of the most important things for a coder in determining POA is careful consideration of identifying the correct principal diagnosis. If you are unsure of your POA status, the list of candidates for appropriate assignment as principal diagnosis under the Uniform Hospital Discharge Data Set (UHDDS) is altered significantly as the principal diagnosis by necessity is POA. If it wasn’t POA, then that diagnosis is eliminated as a candidate for principal diagnosis.

The more interesting focus, however, is on quality metrics across the board. There are certain diagnoses which, when reported as not POA, are considered a measure of poor quality of care on the part of the hospital and these present in a number of different quality metrics.

Just using the list above, I could set up some hypothetical questions. (These are just hypothetical; I could write a book here probably.)

UTI/Pyelo: If not POA, then you also couldn't use it as the local infection for sequencing sepsis as principal diagnosis, i.e., if the local infection that caused sepsis was not POA, the sepsis cannot be POA either.

Encephalopathy: What was the reason for admission according to the doctor? Were they really admitted for the UTI, or was the decision to write that admission order largely driven by the presentation of the patient as confused and encephalopathic. To be sure, some physicians will say it was the altered mental status that sealed the deal.

Chest pain: Do you need to go back and sequence a respiratory or gastroenterological condition as the principal diagnosis? At that point, reporting of chest pain is integral and not reported anyway. If there was no determined etiology for the chest pain, then I suppose there wouldn't be too much impact, other than the obvious question of wondering why a patient who had chest pain passed through the ED and initial admission without the physician ever bothering to mention the patient was having chest pain!

As far as your second question, for infection codes that include the causative organism, assign “Y” if the infection (or signs of the infection) were POA, even though the culture results may not be known until after admission (e.g., patient is admitted with pneumonia and the provider documents pseudomonas as the causal organism a few days later). 

What the provider lists as the first listed diagnosis will often not be selected by the coder as the principal diagnosis. In some cases, the provider’s first listed diagnosis does not even meet UHDDS criteria for selection as the principal diagnosis, so coders have to report the sequencing based on the legal reporting definitions. The provider does, however, (usually) have to state if a condition was POA in order for the coder to designate it as such, or it has to be very clearly present in the ED, history and physical, and/or initial progress note.

There is one coding guideline which SHOULD allow coders some judgement here in the POA section of the Official Guidelines for Coding and Reporting:

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

Diagnoses subsequently confirmed after admission are considered present on admission if, at the time of admission, they are documented as suspected, possible, rule out, differential diagnosis, or constitute an underlying cause of a symptom that is present at the time of admission"

"For infection codes that include the causal organism, assign “Y” if the infection (or signs of the infection) were present on admission, even though the culture results may not be known until after admission (e.g., patient is admitted with pneumonia and the provider documents pseudomonas as the causal organism a few days later)."

Though this guideline exists, I find very few coding professionals willing to apply the “or constitute an underlying cause of a symptom that is present at the time of admission” as the sole determining factor in adopting the diagnosis as POA. They need something a little more concrete to comfortably apply a code, so it’s always safer to query the physician if you’re unsure whether a condition was in fact POA.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro in Middleton, Massachusetts, answered this question on the ACDIS Forum. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.