It clarifies if a diagnosis was present at the time of admission.  Did a fracture occur before the patient was admitted or during the patient's care?  Did a decubitus ulcer (bed sore) occur before the patient was admitted or during the patient's stay?

Present on Admission Overview & History:

• 1992   NCVHS & UHDDS make a recommendation
• 1994  The state of New York implements POA for public health reporting
• 1996  NCVHS Core Health Data make a recommendation
• 1996  The state of California implements POA for public health reporting
• 1999  The Institute of Medicine publishes its report, To Err is Human
• 2000  Continued intense focus from CMS, employers, and advocacy groups to restructure payment for healthcare based on quality of care delivered
• 2003  Consumer-Purchaser Disclosure Project proposed adding a quality indicator on the UB-04 form
• 2004  The NCVHS Workgroup on Quality made its recommendation
• 2004  The NCVHS’ recommendation went to HHS
• 2005  MEDPAC report was sent to Congress
• 05-06  36 bills passed in 24 states related to health strategies to improve  the quality of patient care
• 2006  Provisions were made in the DRA regarding hospital-acquired infections

According to CMS, the POA Guidelines:

• Essential: Joint effort between healthcare provider & coder to achieve complete & accurate documentation, code assignment, & reporting of dx/proc
• Provider: physician or any qualified healthcare provider legally accountable for establishing pt’s dx

The POA Guidelines State That:

• Issues related to inconsistent, missing, conflicting, or unclear documentation must still be resolved by provider, hospital, facility, etc.
• If condition would not be coded & reported based on UHDDS definitions & current official coding guidelines, then the POA indicator would NOT be reported.

The Five Indicator Codes Allowed Are:

• Y-present at the time of IP admission
• N-not present at the time of IP admission
• U-documentation is insufficient to determine if condition is POA
• W-provider is unable to clinically determine whether condition was POA or not
• Exempt-leave blank if condition on the “not applicable” list; only reason why field should be blank

According to the Guidelines:

• Y & N: Must be explicitly documented; i.e. HPT, DM, Asthma
• U: Assign when medical record documentation unclear; should not be routinely assigned/used in very limited circumstances. Coders encouraged to query providers when documentation unclear.
• W: Assign when medical record documentation indicates that it cannot be clinically determined whether or not condition was POA
• Assign Y for conditions that were clearly present, but not dx’d, until after admission occurred–Dx subsequently confirmed after admission are considered POA if, at the time of admission, they are documented as suspected, possible, R/O, differential dx, or constitute an underlying cause of a symptom that is POA