Tip: Take a closer look at POA reporting guidelines

The 2017 ICD-10-CM Official Guidelines for Coding and Reporting brought many changes and updates for coders, and present on admission (POA) reporting was not excluded. Completely understanding POA guidelines is necessary for any inpatient coder or CDI specialist.

Per the Guidelines, POA conditions are defined as those present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, such as an emergency department, observation, or outpatient surgery, are also considered POA. A coder would assign the POA indicator to a principal or secondary diagnosis.

Think of understanding POA indicators as “part two” of understanding coding rules, says Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, and coding regulatory specialist at HCPro, a division of BLR, in Middleton, Massachusetts.

“Once the codes have been assigned for an inpatient record, a coder then must go back and evaluate each one for the appropriate indicator,” Commeree says. Also important to remember is there is no required time frame that a provider must document a condition for it to be considered POA, so CDI professionals can still clarify conditions as POA through their efforts, as well. It could take several days for a provider to assign a diagnosis. Because it may take a provider several days to arrive at a diagnosis does not mean that the condition was not POA. Determination of whether the condition was POA is based on the Guidelines and on the provider’s best clinical judgment, Commeree says, since according to the Guidelines:

“In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period after admission.”

The Guidelines also state that if at the time of code assignment, the documentation is unclear as to whether a condition was POA, it is appropriate to query the provider.

“If we’re not sure if it was POA—it wasn’t explicitly documented as POA, diagnosed prior to admission, or diagnosed during the inpatient admission but seems POA by indication of signs and symptoms—it’s not up to us to decide. A query to the attending provider is the best course to take.”

Editor’s Note: This article originally appeared in JustCoding. To access the original article, click here.