Present on Admission

1. Present on Admission Presented by: Lenore M Whalen, RHIT, CCS,CCS-P

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3. 3 History and Background 2006 Presidential Executive Order Increase transparency in pricing Increase transparency in quality Encourage adoption of health information technology (IT) standards Provide options promoting quality and efficiency in health care

4. 4 CMS/Premier HQID Project Sustained and dramatic improvement continues As performance continues to improve in groundbreaking CMS/Premier pay-for-performance patients lives have been saved Improved quality means more patients receive recommended treatments

5. 5 Evolution of POA Indicator State Adoption POA data collection initial purpose Quality reporting, research Not new to health care NY, 1994 � called other diagnoses Present on Admission CA, 1996 � called conditions Present on Admission Recent adopters FL & MA � 2007 Future adopters All other states Federal mandate Deficit Reduction Act (2/06) October 2007 collection and reporting Move to UB-04, May 2007

6. 6 Mandated MRA By October 2007 Secretary required to ID at least 2 conditions that are: High cost and/or high volume Result in DRG having higher payment when present as secondary diagnosis Could have reasonably been prevented thru application of evidence based guidelines By October 2008 Discharges shall not be assigned to DRG resulting in higher payment if one of ID�d conditions not present on admission

7. 7 What is POA Indicator? Defined as present on admission at time the order for inpatient admission occurs Includes conditions Known at time of admission Present on admission, diagnosed later, and Develop during outpatient encounter, including ED, OBS, or outpatient surgery Identifies comorbidities vs hospital acquired complications

8. 8 POA Mandated Rules of Collection POA applies only to inpatient admissions POA assignment must include principal and secondary codes Admission diagnosis is always defined as present on admission

9. 9 Relationship to ICD-9-CM Supplement ICD-9-CM Guidelines for Coding and Reporting Added to �Official Coding Guidelines� October 2006 Documentation from any provider may be used to determine if condition present on admission Issues related to inconsistent, missing, conflicting or unclear documentation still requires resolution by provider If condition does not follow rules of UHDDS definitions and current coding guidelines, POA indicator not reported

10. 10 Relationship to ICD-9-CM POA guidelines not intended to provide guidance on when condition should be coded Used to apply POA indicator to final set of diagnoses assigned according to ICD-9-CM �official coding guidelines�

11. 11 POA Reporting Guidelines Provides direction on applying POA indicator to final set of diagnosis codes Defines provider as physician/qualified practitioner legally accountable for establishing patient�s diagnosis Includes both principal and secondary diagnoses as well as E Codes List of Exempt Codes Reminder: Admitting Diagnosis and exempt codes do not require POA Indicator

12. 12 POA Reporting Guidelines (continued) POA applied to all claims involving inpatient admissions in general acute care hospitals or other facilities subjected to law/regulation mandating collection of present on admission information

13. 13 Reporting Options Code Y N U W Blank Definition Yes, present at time of inpatient admission No, not present at time of inpatient admission Unknown, documentation is insufficient to determine if condition is POA Clinically undetermined, provider is unable to clinically determine whether condition was POA or not Unreported/Not used, exempt from POA reporting

14. 14 Assigning POA Indicator Condition on �exempt from reporting� list Leave POA indicator blank Only circumstance field may be left blank POA explicitly documented Assign �Y� for any condition provider explicitly documents as being present on admission Assign �N� for any condition documented as not present on admission

15. 15 Conditions diagnosed prior to IP admission Assign �Y� for conditions/diagnoses present prior to admission (comorbidities) Hypertension DM COPD Asthma CHF, etc.

16. 16 Conditions Diagnosed During Admission Conditions clearly present on/before admission Assign �Y� Conditions diagnosed during admission Were clearly present but not diagnosed until after admission Conditions confirmed after admission, if documented as �suspected,� �possible,� �probable,� �rule out.� Includes differential diagnosis or symptom of condition present on admission Condition occurring prior to admission in OP encounter Assign �Y� Prior to written order for IP admit

17. 17 Conditions Diagnosed During Admission Documentation doesn�t indicate condition present on admission Assign �U� if unclear Query physician first! �U� should not be assigned routinely Only used in very limited circumstances Documentation states it cannot be determined if condition present on admission Assign �W�

18. 18 Conditions Diagnosed During Admission (continued) Chronic condition in exacerbation If combo code including both chronic condition and exacerbation Assign �N� if exacerbation was not present on admission �Y� would be assigned to chronic condition If all parts of combo code is POA Assign �Y� to all parts If combo code only ID�s chronic condition & not acute exacerbation, assign �Y� Example: CHF in acute exacerbation

19. 19 Conditions Diagnosed During Admission (continued) Possible, probable, suspected, questionable, or rule out diagnosis at time of discharge If suspected at time of admit, assign �Y� If not present on admission, assign �N�

20. 20 Conditions Diagnosed During Admission (continued) Impending or threatened conditions Symptoms present on admission, assign �Y� Symptoms not POA, assign �N�

21. 21 Conditions Diagnosed During Admission (continued) Acute and Chronic Conditions If acute condition POA, assign �Y� If not POA, assign �N� Assign �Y� even if chronic condition not diagnosed until after admission If one code ID�s both acute and chronic condition, assign according to combination coding quidelines

22. 22 Combination Codes If all parts of combo code POA, assign �Y� Example: Diabetic neuropathy w/uncontrolled diabetes Assign �N� if none of parts were POA Example: COPD w/acute exacerbation and none present on admission; gastric ulcer not bleeding until after admit; status asthmaticus developing after admission

23. 23 Combination Codes (continued) Comparative/contrasting conditions both present or suspected on admit, assign �Y� to all Assign �Y� to infection codes that include causal organism Even if culture result not known until after admission Example: Patient admitted w/pneumonia and physician documents pseuodmonas pneumonia few days after discharge

24. 24 Obstetrical Conditions POA not affected by whether patient delivers or not If complication or obstetrical code is present on admission, assign �Y� Example: Patient admitted in preterm labor If complication/obstetrical code not POA, assign �N� Example: Patient sustains 2nd degree laceration during delivery; fetal distress develops after admission

25. 25 Obstetrical Conditions (continued) If OB code includes more than one DX and any were ID�s as not POA, assign �N� Example: Code 642.7X, pre-eclampsia or eclampsia superimposed on pre-existing HTN

26. 26 Obstetrical Conditions (continued) OB code includes info not DX, do not consider that info in POA determination Example: Code 652.1X, Breech or other malpresentation successfully converted to cephalic presentation Would be coded as breech presentation and assigned �Y�

27. 27 Perinatal Conditions Newborns considered to be not admitted until after birth Any condition present at birth or develops in utero considered POA, assign �Y� Includes conditions occurring during delivery Example: Injury during delivery, meconium aspiration, exposure to Strep B in vaginal canal

28. 28 Congenital Conditions and Anomalies Always considered present on admission, assign �Y�

29. 29 External Cause of Injury Codes Assign �Y� to E Codes occurring prior to admission Example: Patient fell out of bed at home; patient fell out of bed in ED If E Code occurred after admission, assign �N� Example: Patient fell out of hospital bed during hospital stay; patient had adverse reaction to drug after IP admission Medication errors important POA data

30. 30 Barriers from Coding Perspective Conditions not being documented Coder�s nightmare, seeing something listed one time, never mentioned again Not knowing whether patient really had condition, if it cleared up � was there something physician forgot to document?

31. 31 Physician Documentation Can�t determine if POA present without physician documentation Work with CM to obtain needed documentation Include in working DRG info

32. 32 Why POA Collection? State reporting Paid for Performance Need to understand root cause of infections Opportunities for improvement Accurate Clinical and Financial information

33. 33 Action Steps to Take Confirm vendor readiness Confirm coder understanding of guidelines Coding Summary Sheet include POA Check with coding staff re: any questions on implementation Prepare for data collection Physician education CM prep to work with physician to obtain POA designation

34. 34 Conclusion POA supplement to ICD-9-CM Official Coding Guidelines for coding and reporting Affects only inpatient coding In Texas, assigned to all diagnoses codes, except admitting diagnosis and exempt codes Requirement of CMS

35. 35 Summary Be ready for POA implementation Know POA guideline HIM will be responsible IT needs to be prepared Vendors need to include POA collection in software

36. 36 References/Resources Present on Admission Reporting Guidelines � CMS & NCHS Deficit Reduction Act Social Security Act (42 U.S.C. 1395xx(d) HCPro Presentation on POA